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introduction traditional medicine and biomedicine are two branches of medicine with di ering characteristics traditional medicine is based on popular knowledge on the use of medicinal resources and re ects the cultural practices beliefs and socioeconomic factors of a given population in contrast biomedicine is characterized by clinical and experimental studies that outline scienti cally proven ways of treating diseases and involves medical consultations laboratory tests and the use of medicines and pharmaceuticals 12 traditional medicine is more common in rural areas due to the greater availability of medicinal plants in those regions than in urban environments and its greater economic and physical accessibility for rural communities 3 biomedicine on the other hand is more likely to be practiced in urban areas 4 5 6 as accessing medical appointments hospitals allopathic medicines and pharmacies may be easier in those areas than in rural areas 78 e close proximity of rural areas to urban centers can favor hybridization between these different types of medicine and result in biomedical science interacting with the knowledge of localtraditional medicine 910 hybridization is the process by which di erent types of medicine coexist it can a ect the knowledge and use of traditional medicine through the substitution of a medicinal plant for an allopathic medicine or complement the treatment of diseases 11 additionally socioeconomic factors can in uence hybridization 12 13 14 as well as medicinal knowledge as demonstrated in the following paragraphs quinlan and quinlan 15 found that individuals working in the trade had greater knowledge about medicinal plants than those who did not in addition when analyzing the combined e ects of general occupation and formal education level they showed that individuals with a commercial occupation and higher formal education level possessed less knowledge about medicinal plants ese results indicate that different variables can modulate medicinal knowledge although it has been shown that an individuals sex and education level may be correlated with their knowledge of local medicine this varies across geographic regions and income levels higher education levels generally provide betterpaying jobs 15 16 17 this can lead to individuals having greater purchasing power with respect to allopathic medicines and a closer approach to biomedicine in rural communities women are generally responsible for the healthcare of family members which entails them having greater knowledge about medicinal resources than that possessed by men in their communities 18 currently the impact of access to biomedicine on knowledge of local medicine and how that might vary with an individuals sex and level of education is not understood some studies have shown that the elderly are more likely to prefer traditional medicine over biomedicine 1920 and generally have greater knowledge about traditional medicine than young individuals 21 22 23 however the impact of the proximity to biomedicine if any on this knowledge is not clear in other words do older people with greater access to biomedicine have less knowledge of medicinal plants than people of a similar age with less access to biomedicine similarly the impact of the number of cohabitants in residences on their medicinal knowledge has not yet been explored in depth andriamparany et al 3 found a positive correlation between the number of residents in a household and their use and knowledge of medicinal plants however alqethami et al 24 found no such correlation is divergence in results highlights the need for further studies like these andor investigations into other potential factors that may interact with the number of cohabitants in a given residence and influence their use and knowledge of medicinal plants different types of relationships can occur between ones socioeconomic characteristics and their knowledge of medicinal plants 18 furthermore access to biomedicine favors the combined use of biomedicine and traditional medicine 12 is combination leads us to question whether close proximity to urban centers can modify the predictive force between socioeconomic variables and consequently modify its influence on the knowledge and use of medicinal plants assessing this question is of significant importance because it allows for a better understanding of not only the predictive role of socioeconomic variables in the relationship between people and the use of medicinal plants but also in the structuring of local medical systems hence in this study we aimed to assess how proximity to biomedicine influences the relationship between socioeconomic variables and certain aspects of medicinal knowledge materials and methods study area e study was conducted in six communities located within catimbau national park sítio igrejinha breus dor de dente muquém túnel and açude velho parna catimbau is located in the state of pernambuco between the geographic coordinates 8 °29′017″s and 37 °20′083″w has a total area of 6229410 ha and covers three municipalities buíque tupanatinga and ibimirim a total of 325 inhabitants with approximately 200 adults and 125 minors were distributed from 109 families living in the six selected communities parna catimbau was established as an environmental protection area in 2002 however these communities were living there prior to this establishment land expropriation processes have not been completed and have generated local socioenvironmental conflicts 2728 e region is a semiarid type of climate 29 according to the köppen classification e total rainfall varies between municipalities but generally has an annual average of less than 700 mm and the annual average temperature is approximately 23 °c e vegetation consists of a mosaic of arboreal and shrubby caatingas some of the dominant plant families found at the site are fabaceae euphorbiaceae boraginaceae cactaceae malvaceae bromeliaceae and asteraceae 2830 profile of the populations of parna catimbau most of the local population live below the world bank poverty line and are highly dependent on forest resources e main occupation in the region is related to agriculture however most families incomes come from the sale of animals especially that of goats several families within the park receive support from nongovernmental and governmental organizations such as the bolsa família program more than half of their homes are built with mud and wood and do not have sewers or toilets streets are either paved or unpaved 2728 families living within parna catimbau are isolated because of the distance from markets and commerce in urban areas in addition as they live within environmental protection areas they are more susceptible to poverty due to land use restrictions 28 e closest urban center to parna catimbau is vale do catimbau where community members travel 25 min to 1 h to access schools andor health posts because of the lack of such facilities within parna catimbau in addition since 2005 a nongovernmental organization called amigos do bem has offered the families of parna do catimbau employment opportunities through plantation of cashew and nut processing as well as housing that is situated closer to schools with basic and complementary education 31 taking the urban center of vale do catimbau as the closest place that allowed people access to biomedicine ie allopathic medicines and medical consultations the distance of each community was calculated using google maps and 2 evidencebased complementary and alternative medicine gps we did not consider the travel time of residents to the urban center as all travel is via a single main unpaved route motorized vehicles are the common mode of transport therefore a shorter distance reflects a shorter travel time e proximity of the six communities to catimbau valley ranged from 11 to 229 km among these communities igrejinha which has the largest number of inhabitants is closest to the catimbau valley being only 113 km from this urban center e other communities are located between 156 km and 229 km from vale do catimbau ethical legal aspects is study was approved by the ethics and research committee of the federal university of pernambuco before data collection all the participants were informed of the study objectives ose who agreed to participate in the study were asked to sign the free and informed consent term to meet the legal requirements of research involving human beings according to the current legislation of the national health council data collection tabulation and statistical analysis all homes in the six communities were visited to conduct a sample census houses without residents or those with residents who insisted on interviewing at another time were excluded from the sample after the third attempt in each community structured interviews were initially conducted with all residents aged 18 years with a total of 102 informants during the interview information was on socioeconomic factors such as age gender employment number of people per household family income and education was collected en using the freelist technique each informant was asked to indicate the medicinal plants they knew and what purposes they had used them for a preliminary analysis of the collected data was then carried out and it was found that seven informants did not indicate some of the socioeconomic data especially those related to income a possible reason for this is the local conflict that was generated with the creation of the park which has caused fear in the informants about possible expropriation of their lands erefore we chose not to include the family income variable in the analysis to avoid reducing the sample size in addition 15 informants did not list medicinal plants and admitted in this study that they did not know or did not want to divulge this information we aimed to assess whether the relationship of each variable with local medicinal knowledge is modified when we consider the interaction between them and the distance from the urban center so we chose to include only individuals who demonstrated knowledge about medicinal plants in the sample consequently two criteria were adopted to define the final sample of informants to be considered in our study having made available all socioeconomic data and having answered the free list on medicinal plants based on these criteria the responses of only 80 participants were assessed we considered the central distance of displacement in each distance group along the central route to the nearest urban center with access to biomedicine as a measure of access to biomedicine we assumed that the community closest to the catimbau valley overcomes the distance barrier more easily and has easier access to biomedicine than communities farther away from the catimbau valley e most distant group from vale do catimbau included informants from the communities açude velho breus dor de dente muquém and tunnel meanwhile the closest group comprised informants from the igrejinha community e age of an individual and number of people per household were not categorized interviewees formal education level was calculated using the number of academic years taken from the first grade of elementary school for example an informant who studied up to the fourth grade of elementary school would have had four years of formal education ere were no informants with a higher education or graduate degree sex and distance to the urban center were tabulated as discrete numerical variables as follows 1 for females or informants from the close group and 2 for male informants or informants from the distant group although biomedicine considers the symptoms of diseases mentioned by the interviewees as mentioned of diseases and not necessarily mentioned therapeutic complaints as a disease in this study the diseases andor symptoms treated medicinally were considered as medicinal targets representing the informants perception of diseases treated with medicinal plants drawing from 32 erapeutic targets were classified into body systems based on the international statistical classification of diseases and related health problems 10th revision 33 erapeutic targets of religious nature were categorized as spiritual diseases after classification the number of body systems treated with the medicinal plants of each informant was counted e measures used as response variables to assess the influence of social variables on knowledge of medicinal plants among the distance groups were the number of known medicinal plants the number of therapeutic targets cited by the informant and the number of body systems treated by medicinal plants to test the hypothesis that ease of access to the urban center can modify the explanatory power of the interactions of social variables on the knowledge of medicinal plants generalized linear models were performed for each dependent variable models were created with and without interactions between the independent variables in addition to a null model for each model the akaike information criterion corrected for a small sample 34 and δaicc were calculated models with δaicc 2 were selected 35 reduction in the selected models was performed using the likelihood method e variables number of ethnospecies and number of therapeutic targets were transformed into square roots and a gaussian error distribution was used to create the models for a variable number of body systems a poisson distribution was used to create the models e independent variables in the glms were age sex number of inhabitants per household and education level we chose not to include informants occupation as an independent variable in the glms because of the lack of information from some informants and the consequent reduction of sample size all statistical tests were performed using the r software 36 results models with the interaction of variables such as the number of therapeutic targets and number of ethnospecies did not prove to be plausible models but were likely to occur age was the only social variable that influenced the informants knowledge of ethnospecies and therapeutic targets old adults showed greater knowledge of ethnospecies and therapeutic targets than that by young adults distance from the urban center did not influence the knowledge of the number of ethnospecies and therapeutic targets ie people from communities both near and far from the urban center had similar knowledge about ethnospecies and therapeutic targets however the distance from the urban center when interacting with education level influenced the knowledge of body systems treated by medicinal plants among the informants in other words people with higher education and from communities far from the urban center knew a greater number of body systems treated by plants compared with the people with higher education from communities near the urban center however when analyzing the influence of education separately we found that people with higher education cited fewer body systems treated with medicinal plants distance from the urban center alone did not have a considerable influence on the number of body systems treated with medicinal plants discussion by analyzing different measures of knowledge we were able to show that elderly people possessed greater knowledge of ethnospecies and therapeutic targets in catimbau is can be explained by the fact that older people have had greater opportunity to try different medicinal species for the same therapeutic purpose andor experience a greater diversity of diseases in the course of life compared to younger people in addition older people may be more likely to try different medicinal plants than that by younger people as indicated by previous studies 37 38 39 this may occur locally and generate greater medicinal knowledge we expected that a greater number of cohabitants would diversify the experience of family members in the use of medicinal plants for the treatment of diseases which is consistent with the findings of alqethami et al 24 our 4 evidencebased complementary and alternative medicine findings suggest that other factors may modulate this relationship gender is recorded as a variable that can directly or indirectly affect knowledge about medicinal plants as it is associated with other factors such as the type of work performed by men and women 12 studies have reported that in communities where women play the role of caretakers and are responsible for collecting medicinal resources they have a greater plant knowledge 18 40 41 42 however if a man is involved in agricultural activities and is responsible for collecting medicinal resources from forests his knowledge of medicinal plants may be more expansive than that of the women 27 sometimes men perform the role of healers in some indigenous brazilian communities which means that their knowledge of medicinal plants is more extensive than that of the women 18 however some studies have shown no relationship between sex and knowledge of medicinal plants 374344 as was found in our study for the communities studied in catimbau in general the advancement of schooling enables jobs with better pay 15 which can increase individuals purchasing power and favors the acquisition of pharmaceutical drugs indirectly the increase in schooling may have a negative effect on the knowledge and use of medicinal plants as reported in several studies 15 a greater purchasing power of pharmaceutical drugs reduces peoples dependence on natural medicinal resources 47 however we did not find a relationship between the number of known species and the level of education which is consistent with findings of other studies 4849 we recorded a decrease in the knowledge of the number of body systems treated by medicinal plants with the advancement of schooling is decrease in the knowledge of body systems treated with medicinal plants may be related to the health of the individual as a previous study suggests that healthier individuals tend to have a higher level of education 50 but this needs to be tested with the methods used in our study in addition accessing schools requires the residents of catimbau to relocate to nearby urban centers which may provide greater contact with biomedicine consequently the inclusion of biomedicine in the treatment of diseases can over time interfere with knowledge about medicinal plants as people may prefer the use of biomedicine and retain less knowledge about medicinal plants as recorded in the study by alqethami et al 24 people with higher education are likely to have greater contact with biomedicine directly influencing the choice between the use of medicinal plants and biomedicine moreover people with higher education levels are more familiarized with andor educated about the treatment of biomedicine for new therapeutic targets compared with the people with less education such as those in the catimbau region many rural communities lack basic health services and inhabitants are forced to travel to urban centers to access them is physical isolation can provide residents with greater knowledge of medicinal plants by increasing their dependence on them 9 moreover contact with biomedicine may not interfere with knowledge of medicinal plants 711 in catimbau the distance of isolation did not influence the three aspects of medicinal knowledge analyzed in this study however the interaction of distance from the urban center with schooling proved to impact an individuals medicinal knowledge e interaction between schooling and distance to urban centers positively influenced knowledge about the number of body systems treated by medicinal plants ie informants from distant communities with higher education knew a greater number of body systems treated by medicinal plants than informants with higher levels of school education from nearby communities an increase in schooling likely favors better knowledge of the characteristics and symptoms of some diseases which can improve the targeting and choice of plants to treat a disease in specific parts of the human body however this knowledge needs to be incorporated into practice so that it becomes assimilated by the community which may not happen in communities close to the urban center due to greater ease of access to biomedicine in this study informants from more distant communities did not mention any pharmaceutical drug for the treatment of a particular therapeutic target as an alternative to replace a particular medicinal plant which differs from what was observed in the case of informants from communities close to urban centers in addition informants from distant communities commented that they had used medicinal plants for the treatment of a specific therapeutic target more recently than had informants from communities in closer proximity to the urban center e findings of our study revealed that distance from the urban center can interact with other socioeconomic variables and generate a differentiated effect on the knowledge of medicinal plants which makes the medicinal knowledge of each community complex is indicates the importance of considering the set of variables that characterize the social and ecological context in which populations are situated to enhance the accuracy of generating hypotheses about a given communitys medicinal knowledge and its implications for understanding the structure and resilience of medical systems e interaction between individuals can influence knowledge about medicinal plants and the communities we studied are consisted of related individuals however we did not evaluate the interaction between communities in our study erefore we suggest that in future studies similar approaches should be considered in the analysis data availability e datasets generated during andor analyzed during the current study are available from the corresponding author on reasonable request ethical approval is study was approved by the ethics and research committee of the federal university of pernambuco conflicts of interest e authors declare that there are no conflicts of interest regarding the publication of this paper

we aimed to evaluate how proximity to urban areas interferes with the relationship between socioeconomic variables and various aspects of medicinal plant knowledge e study was conducted in six communities of the catimbau national park parna catimbau in the state of pernambuco eighty participants were interviewed e communities were divided into two groups according to their distance from the nearest urban center socioeconomic data and information on medicinal plants were collected through semistructured interviews subsequently generalized linear models were generated to verify the in uence of the interaction between the variables on medicinal knowledge we observed that proximity to the urban center in uenced the relationship between the level of education and the knowledge of body systems treated by medicinal plants we concluded that environmental variables can generate a di erentiated e ect on the in uence of socioeconomic factors on ones knowledge of medicinal plants

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with the rising incidence of type 1 diabetes hispanic youth are being diagnosed with diabetes more than ever in fact the search for diabetes in youth study has found larger increases in the annual incidence rates among hispanic youth compared to white nonhispanic youth in addition a recent metaanalysis reported that ethnic minority youth including hispanic youth display higher hba1c levels with more acute and longterm complications than wnh youth studies have often found that hispanic youth with t1d have poorer glycemic control and lower rates of adherence compared to wnh youth however findings have been inconsistent with a few studies reporting no differences in glycemic control between hispanic and wnh youth after adjusting for socioeconomic status hispanic youth with t1d may be at greater risk for complications than wnh youth if they experience poorer glycemic control and lower rates of adherence especially during adolescence it has been reported that nearly twothirds of adolescents engage in suboptimal diabetes management defined as the amount precision and regularity of behaviors carried out by patients or family members to establish maintain or monitor diabetic control hispanic youth are even more likely to fall into a highrisk group of adolescents than their wnh counterparts with poor diabetes management and glycemic control research indicates that changes in autonomy support youth regimen responsibility and family conflict are important developmental considerations that influence disease care and diabetes management over the course of adolescence these changes may be most amenable to intervention during early adolescence defined in the current study to include children ranging from ages 9 to 14 recent research has found that parental autonomy support is associated with improved diabetes management including maintenance of frequent blood glucose monitoring parent autonomy support has been defined as being responsive to youths perspectives and needs providing choices encouraging initiative and reasoning about expectations or requirements parent and adolescent report of autonomy support have been associated with perceptions of shared diabetes care responsibility among family members studies suggest that shared regimen responsibility is associated with improved psychosocial outcomes and improved diabetes management additionally there is consistent evidence of a relationship between increased diseaserelated family conflict in adolescence and reduced diabetes management as well as suboptimal glycemic control increases in family conflict and perceived parental criticism may interfere with the quality of collective problemsolving between parents and adolescents leading to poorer disease outcomes while a developmentally sensitive understanding of diabetes management in adolescence is emerging the research in this area is understudied with regard to ethnic minority youth as in the research described above for largely wnh populations it is suspected that characteristics of the parentadolescent relationship are salient in diabetes management for hispanic adolescents due to the centrality of family family connectedness is a predominant aspect of family functioning and characteristic of family cohesion within collectivistic family orientations like traditional hispanic families literature suggests that hispanic youth may have increased parental supervision support and control rooted in cultural values like familismo respeto and educaci on in an effort to promote communication and familial support these family values have been associated with positive wellbeing and psychological functioning in hispanic youth in at least one study higher levels of family connectedness were associated with lower levels of asthmarelated functional limitation in hispanic youth findings like this suggest that family connectedness may be used to help support the management of chronic illness like asthma and t1d literature suggests that similar to asthma management family dynamics are salient to t1d management hispanic values and family connectedness may have implications for hispanic families of youth with t1d as increased diseasespecific parent involvement and support may be protective factors that can be further amplified in intervention with families of hispanic youth with t1d crosssectional studies have suggested some family related differences in adolescent diabetes management for hispanic youth including increased parent supervision of diabetes management tasks and increased diabetesrelated family conflict compared to wnh youth in addition hsin greca valenzuela moine delamater found that family support mediated a significant relationship between adolescent responsibility and improved adherence in a sample of hispanic youth with t1d differences in hispanic culture and family values may result in differences in the experience of autonomy support shared regimen responsibility and family conflict over the course of adolescence for hispanic youth and their families understanding culturespecific differences that exist for hispanic youth and families may be an important consideration for pediatric psychologists treating youth with t1d given findings that hispanic youth with t1d have disparate health outcomes the current study uses a longitudinal multisite database to compare diabetes management trajectories of hispanic and wnh youth with t1d over the course of late childhood and early adolescence in addition the study compares youths trajectories on a variety of variables that have been previously shown to impact diabetes management during adolescence it is hypothesized that the subset of hispanic youth will have different longitudinal trajectories on a variety of predictors and outcomes in comparison to the larger wnh group of youth specifically the limited pediatric diabetes research suggests that family variables may act as a protective factor for hispanic youth we hypothesize that hispanic families may remain more involved in regimen responsibility have fewer changes in autonomy support and a lower rate of family conflict compared to wnh youth methods twohundred and thirtynine youth with t1d were recruited from three universityaffiliated pediatric diabetes clinics within the united states as part of a larger longitudinal study of diabetes regimen and management throughout early adolescence parents identified youth as wnh hispanic and africanamerican reports of longitudinal data from this study have been previously described in drotar et al rausch et al rohan et al rohan et al andwu et al this is the first report from this study focusing on the comparison of diabetes management trajectories across ethnicities youth were recruited during routine outpatient clinic visits inclusion criteria included duration of t1d for at least 1 year between 9 and 11 years of age at recruitment english speaking no plans to relocate out of the area during the study duration and absence of secondary causes for t1d diagnosis exclusionary criteria included active involvement in foster care presence of severe psychiatric disorders or comorbid chronic conditions that required intensive treatment regimens or diagnosis of intellectual andor developmental disabilities participants and their maternal caregivers completed study measures at four time points youth received 35 in gift cards and caregivers received 20 cash for completing measures at each visit additionally participants received 5 for providing blood glucose records from their blood glucose meter or logbook at each visit each of the three universityaffiliated institutional review boards approved the study the overall recruitment rate was 665 reasons for declining participation in the study included being too busy difficulties maintaining transportation and other caregivers provided signed informed consent and youth aged 11 years and older provided written assent while youth under 11 years of age provided verbal assent for participation this report includes all wnh and hispanic participants who completed measures of interest during at least one time point other minority groups were excluded in the present study due to small sample sizes and the focus on hispanic youth overall at baseline the study yielded 211 participants 178 wnh and 33 hispanic youth participants as well as their maternal caregivers participant attrition during data collection has been described previously as low approximately 4 from baseline to 3 years reasons for attrition include transfer of medical care to a provider nonaffiliated with the study family too busy to participate family relocation from the geographic area and family lost to followup wu and colleagues found no significant demographic differences between participants who completed assessments at all time points versus those who did not in the study measures demographic variables caregivers provided information on youths date of birth gender raceethnicity duration of diagnosis family income maternal education and household composition youth age was calculated from birth date and date of study assessments blood glucose monitoring frequency blood glucose monitoring frequency was evaluated using data downloaded from youths blood glucose meter for the previous two weeks starting with the day prior to the assessment visit if one or more of the blood glucose meters were not accessible at the time of the visit information from youths blood glucose monitoring logbooks was used frequency of blood glucose monitoring were recorded and the average daily blood glucose monitoring frequency over the last two weeks was calculated glycemic control hemoglobin hba1c levels were obtained at six month intervals from baseline to 3 years post baseline blood samples obtained by finger stick at study visits were processed and analyzed by one central laboratory using the tosohg7 method family conflict family conflict regarding diabetes management was assessed with the diabetes family conflict scale the measure evaluates the amount of conflict around tasks of diabetes management it consists of 19 items on a 3point likert scale ranging from 1 to 3 total scores may range from 19 to 57 with higher scores indicative of higher family conflict the measure has demonstrated good reliability and validity as well as good internal consistency for caregivers and for youth youth as well as their maternal caregiver completed this measure at each time point internal consistency across study time points ranged from 85 to 87 and 81 to 87 in the current sample regimen responsibility primary responsibility for diabetes care was assessed through caregiver report using modified versions of the continuous subcutaneous insulin infusion use survey and diabetes independence survey depending on type of insulin therapy used the measures have demonstrated both adequate reliability and validity youth report was not obtained as the original measures were not validated for use with an adolescent population the dis was modified for the current study to allow for items to address modern diabetes management recommendations the dis was also modified to allow for assessment of caregiver perception of which family member is primarily responsible for monitoring and carrying out tasks associated with injections to increase its comparability to the modified csiiuse survey overall the modified dis included 38 items while the modified csiiuse survey included 28 items both the modified dis and csiiuse survey were scored based on who is responsible with response options of parent shared child or not applicable cronbachs alphas for the two measures ranged from 88 to 95 across time points in the current sample for both respective measures an average responsibility score was calculated by averaging scores across the responsibility items participants were classified as having a caregiver primarily responsible if the average responsibility score was between 1 and 149 shared responsibility of diabetes tasks if the score was between 15 and 249 and youth primarily responsible if the score was between 25 and 3 autonomy support parental support for youth autonomy in diabetes management tasks was assessed using a modified form of the diabetesspecific parental support for adolescents autonomy scale specifically the measure evaluates parental behaviors that promote youths autonomy in the management of their diabetes regimen this measure has demonstrated adequate reliability and validity maternal caregivers and youths were each asked to respond to six items on a 5point likert scale ranging from 0 to 4 in regard to the frequency of autonomysupporting behaviors two items were added to the original measure to assess for parental support of youth autonomy in regard to blood glucose monitoring and carbohydrate counting item responses were summed for a total score ranging from 0 to 24 with higher scores indicating higher levels of parental support for youth autonomy cronbachs alphas for maternal caregivers and youth at baseline were 068 067 at 1year were 067 072 at 2year were 078 070 and at 3year were 075 072 respectively diabetes selfmanagement behaviors related to diabetes selfmanagement were measured using the diabetes selfmanagement profile a 25item structured interview administered to both youth and their caregivers the profile assesses diabetes management for the previous 3 months through openended questions addressing domains of blood glucose monitoring diet exercise hypoglycemia management and insulin administration the dsmp includes items with a variety of response scales a total selfmanagement score is calculated by summing all items and domain scores are computed by summing items within that domain higher scores are indicative of more meticulous selfmanagement behaviors overall the dsmp has demonstrated good internal consistency moderate agreement between reporters and strong interrater agreement additionally the measure has demonstrated good predictive validity between caregiver and youth report of selfmanagement behaviors and glycemic control internal consistency across time points ranged from 66 to 71 for maternal caregiver report and 60 to 69 for youth report analytic technique all analyses were conducted using ibm spss v20 differences in participant characteristics between wnh and hispanic youth were examined through independent ttests for age and chisquare tests for all other demographic variables similarly baseline group differences on bgmf hba1c autonomy support diabetes management and regimen responsibility were assessed by conducting independent ttests with baseline observations when appropriate welchs ttests were utilized rather than students ttests to address violations of the assumption of homogeneity of variance significant baseline differences were further examined using ancova models to control for the effects of demographic variables in order to examine participant trajectories over time on these same variables we utilized an individual growth curve modeling approach this approach which is functionally equivalent to multilevel modeling allows for examination of growth trajectories at both the aggregate and individual levels of note while growth curve models typically have sample sizes of at least 100 models have been successfully fit to samples as small as 22 and allow for comparisons among unequal groups our unconditional models were fit to samples well over 100 the same analytic process was conducted with each dependent variable separately first we determined the best fitting unconditional growth model by comparing the à2 log likelihood statistics of a series of increasingly sophisticated nested models until no further significant improvement in fit was detected this series began with a simple model including only a fixed intercept parameter and one additional parameter was added in each subsequent model in the following order random intercept fixed linear slope random linear slope and fixed quadratic slope time was represented in all models by chronological age centered at the sample mean age at time one second between group differences between wnh and hispanic youth on growth curve intercepts and slopes were assessed by adding ethnicity and an ethnicitybytime interaction to the best fitting unconditional growth curve model for each dependent variable finally if a statistically significant ethnicitybytime interaction was detected we added to the model the income maternal education and household composition variables as well as the interaction of each with time in order to control for the potential confounding effects of these demographic variables the spss mixed procedure with full maximum likelihood estimation was used for all growth curve models this procedure addresses the potential influence of missing data by weighting observations without missing data points more heavily than observations with missing data points additionally sensitivity analyses of missing data were conducted and indicated that data were missing completely at random results baseline comparisons betweengroup comparisons of baseline participant characteristics are displayed in table i the groups differed on household composition with the hispanic group composed of a significantly greater percentage of participants from singleparent households compared to the wnh group x 2 ¼ 114 p ¼ 001 betweengroup differences were also detected on the income variable x 2 ¼ 262 p ¼ 001 with the hispanic group including more individuals in the lower income levels compared to the wnh in terms of insulin administration method 697 of hispanic participants used injection rather than a pump or pod at baseline whereas only 376 of wnh participant used injection x 2 ¼ 117 p ¼ 001 the groups did not significantly differ on age gender or maternal education baseline betweengroup comparisons on the outcome variables of interest are displayed in table ii on average hispanic participants checked their blood glucose less frequently than wnh participants d ¼ 043 p ¼ 02 hispanic participants had higher hba1c levels at baseline compared to wnh participants d ¼ 062 p ¼ 002 the groups also differed on both child and maternal reports of family conflict with hispanic families generally reporting higher levels of conflict d ¼ 49 p ¼ 01 and d ¼ 068 p ¼ 005 for child and maternal reports respectively when controlling for household composition income and insulin administration method differences remained significant for hba1c f ¼ 376 p ¼ 05 and both child and maternal reports of family conflict f ¼ 402 p ¼ 05 f ¼ 13002 p 001 respectively however bgmf did not differ after controlling for these variables f ¼ 065 p ¼ 42 comparisons of longitudinal trajectories growthspecific curve estimates ethnicity main effects and interaction effects for all dependent variables are displayed in tables iii andiv except where noted all models include random effects for linear slope for most variables the data were best fit by linear growth models however for maternal reports of regimen responsibility and family conflict quadratic growth was observed estimates of intercepts for both groups were statistically significant for all dependent variables indicating nonzero estimated average values for each group at age 1054 similarly slope estimates for each group were significant on most but not all dependent variables indicating that most variables changed significantly over time specifically youth in both groups had less bg monitoring greater hba1c and less autonomy support slope estimates for maternal reports of autonomy support and regimen responsibility were not significant for the hispanic group suggesting that there was relatively no to little change over time though this may have been a function of the relatively small sample size of that group slope estimates for family conflict by maternal report were only significant for the hispanic group and suggested decreasing family conflict over time as seen in table iv significant main effects of ethnicity were found for hba1c child reports of autonomy support and family conflict and maternal reports of conflict these main effects are indicative of significant differences in the groups at baseline and are qualitatively consistent with the ttest results in table ii given our focus on ethnicitybased differences in growth trajectories we were most interested in examining ethnicitybytime interaction effects a significant interaction was detected for maternal report of diabetes selfmanagement even after controlling for income maternal education and household composition this interaction is displayed graphically in figure 1 regarding selfmanagement as measured by dsmp wnh maternal caregivers reported significantly decreasing scores over time whereas hispanic maternal caregivers reported smaller and nonsignificant decreases over time discussion this study aimed to understand differences between hispanic and wnh youth in regard to diabetes management trajectories over early adolescence in addition longitudinal data was used to compare hispanic and wnh family trajectories on a variety of diseasespecific family variables that have been previously shown to impact disease management during this developmental period results indicated that similar to wnh youth hispanic youth reported decreasing autonomy support the study also examined the developmental trajectory of diabetes management behaviors and health outcomes in this sample and found as expected worsening blood glucose monitoring frequency and glycemic control for all youth during early adolescence while both hispanic and wnh youth had worsening selfmanagement and health outcomes during this period this study highlights that there may be some differences in the acceleration of these processes hispanic caregivers in this study reported a more gradual change in youths diabetes management over early adolescence the present study cannot clearly connect maternal report of a more gradual change in diabetes management to the diseaserelated family variables studied here there were no other differences over time by ethnicity on the variables assessed it may be that there are differences in how hispanic caregivers perceive diabetesrelated behaviors and family interactions as suggested by some of our data future studies should measure differences in acculturation and assess how acculturative status may relate to differences in child and mother perception of these important diabetesrelated variables however it is also important to note that spanish translations of the diabetes selfmanagement profile the disease management measure used in the present study have demonstrated strong parentchild concordance and a significant relationship between hispanic caregiverreport and both a1c and physician perceptions of selfmanagement if hispanic motherreport of a slower trajectory of decline in diseasemanagement is accurate future studies that randomize hispanic youth to various groups and manipulate variables such as autonomy support family conflict and regimen responsibility through intervention may be helpful in further understanding the role of these interactions in the disease management behaviors of hispanic youth it is important to note that despite finding that mothers report a more gradual change in diabetes management and decreasing family conflict over time for hispanic youth there was clear evidence of increased risks for this group at baseline hispanic youth had significantly poorer glycemic control less blood glucose monitoring behavior and more family conflict compared to wnh youth these findings ranged from moderate to large effect sizes while the literature has at times been inconsistent about these disparities for hispanic youth with diabetes evidence appears to be accumulating regarding clear disparities and poorer outcomes in the current study there were clear differences between hispanic and wnh youth on a variety of variables including household composition annual household income and insulin regimen baseline comparisons suggest that ethnic group differences exist after controlling for these variables the existing literature remains mixed on the effects of ses versus ethnicity on healthrelated disparities however it is important to consider the role of variables outside of the family system that may disparately affect hispanic youth with diabetes hispanic youth functioning within problematic school community and healthcare systems may have inadequate supports for optimal disease management despite having similar family support to wnh youth studied future studies should also examine the role of other systems variables beyond the family to better understand these existing disparities the present study is not without limitations the focus on hispanic families treats individuals of different national origins the same despite important differences in hispanic subgroups based on many factors including cultural beliefs socioeconomic status and acculturation status these variables were not assessed in the current study additionally the majority of the hispanic youth in the current sample came from one geographic region there are likely important differences among hispanic groups that suggest the critical need for more research in this area especially given the growing population of hispanic youth with t1d in the united states furthermore the limited sample size of hispanic participants in this secondary data analysis from a large longitudinal multisite dataset limits our confidence and suggests the need for continued efforts to recruit larger samples of ethnic minority youth in longitudinal research of this kind future research should directly assess these important variables in a larger representative sample of hispanic families of youth with diabetes in the study three selfreport measures were modified from their original forms in order to more accurately assess regimen responsibility and autonomy support given changes in diabetes management and to account for all participant perspectives cronbachs alphas were calculated for all assessment tools utilized in this study including the updated measures while the data from these measures provide initial evidence regarding the trajectories of hispanic youth with t1d further psychometric properties on the consistency validity and reliability of these adapted measures and their crosscultural use is needed a final limitation of the present study is that these findings focus on early to midadolescence and may not extend to later adolescence and early adulthood a critical developmental transitional period it would be important to investigate what happens over the course of late adolescence and transition into adulthood for hispanic youth and their families managing diabetes young adults are at increased risk for diabetesrelated complications and are the least likely group to maintain consistent medical care for disease management in at least one study parental support was found to decrease psychological distress and improve glycemic control in emerging adults with t1d more research might suggest that parental support and transition readiness interventions could target different trajectories in hispanic youth and families compared to wnh families despite the limited sample size this study presents important movement towards exploring change in family and youth behaviors over a vulnerable developmental period and considering how these changes may differ for ethnic minority populations because diseasespecific family variables have been shown to be critical to diabetes outcomes they are an important part of effective intervention in this population therefore understanding common trajectories for hispanic youth has the potential to influence treatment in this population this study found decreases evidence of decreasing autonomy support and diabetes selfmanagement in both wnh and hispanic families of youth with diabetes during this developmental period it suggests that addressing these factors in treatment for hispanic youth and families may be as effective as it is when studied in largely wnh intervention studies further differences in youth and mother report of autonomy support in hispanic families may speak to the importance of considering factors impacting perception of these variables intergenerationally in treatment settings if further research more robustly finds that a slower trajectory of worsening disease selfmanagement for hispanic youth this protective factor could be bolstered in culturally competent ways by clinicians in pediatric diabetes centers there is evidence that focusing on strengths such as limited erosion of family involvement in diabetes management is an effective tool for helping improve outcomes in pediatric diabetes furthermore clinical interventions should also consider individual characteristics of the identified patient in order to adequately assess transition readiness for diabetes selfmanagement and potential unique individual barriers like patient beliefs and values future studies are needed to further identify culturally competent strategies for supporting families of youth with diabetes during adolescence and into the transition to adulthood longitudinal studies like this one can help us learn how disparities grow and change over time and may be essential in working to close the gap for ethnic minority youth with t1d conflicts of interest none declared

objective ethnic minority youth with type 1 diabetes t1d often have poorer glycemic control and lower rates of adherence compared to white nonhispanic wnh youth variables such as family conflict autonomy support and youth regimen responsibility have been shown to change over adolescence and impact diabetes management however these factors have been investigated in predominantly white samples few studies have examined potential differences in these variables and their trajectories for hispanic youth over early adolescence methods youth with t1d 178 wnh and 33 hispanic youth participants as well as their maternal caregivers 174 wnh and 32 hispanic maternal caregivers completed measures of diabetesspecific autonomy support diabetesrelated family conflict regimen responsibility and blood glucose monitoring frequency at 4 timepoints over a 3year period results at baseline hispanic youth had significantly poorer glycemic control more family conflict and fewer blood glucose checks on average compared to wnh youth similar to wnh youth hispanic youth have increasing independence for regimen tasks and decreasing parent autonomy support during this developmental period however while hispanic youth had worsening diabetes management during early adolescence as did wnh youth hispanic parents reported a more gradual change in youths diabetes management over early adolescence conclusions this study presents an important contribution to the existing literature on youth with t1d findings suggest potential strengths and targets for hispanic youth navigating diabetes management during the adolescent period it is important to continue to investigate the trajectories of ethnic minority youth with diabetes

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introduction as of midoctober 2020 more than 90 countries across the world had imposed some form of lockdown in the wake of the covid19 pandemic 1 lockdowns range in scope and duration but all imply a degree of social isolation as well as disruption from routine social educational andor work activity previous research which predates covid19 indicates that following social isolation and disruptions from work routines mental wellbeing may decline 2 3 4 5 6 and whether people live together with others or not can be an important stratifying factor 7 in addition a review of mental health following more extreme measures of quarantine finds longterm psychological sequelae 8 and studies have found increased levels of depression stress and anxiety among several groups such as singles females and people who lost their jobs because of lockdowns 9 10 11 taken together this literature has raised the concern of a second pandemic of morbidity due to mental health problems following covid19 12 and calls have been made for prioritizing highquality research on the mental health effects of the pandemic 13 recent research examines mental wellbeing following covid19 and the associated lockdowns four populationrepresentative studiesin the uk the us austria and franceappear in the literature together with a study across eight countries using respondents driven sampling all studies report worse mental health in spring 2020 relative to previous years 612 14 15 16 17 ettman and colleagues for instance find a much greater prevalence of depressive symptoms among adults in the us in april 2020 relative to 20172018 just as sønderskov and colleagues do for denmark in early april 2020 relative to 2016 this work while important has two key limitations first among the national studies the uk the us and france all rank in the top 15 worldwide in covid19 deaths per population as of november 30 2020 18 this circumstance leaves open the question of whether experienced national severity of the pandemic or the social and work restrictions imposed by a lockdown per se drive results second none of these studies includes measures of mental health andor wellbeing immediately before the lockdown the absence of baseline mental health information in weeks before the lockdown raises the concern of confounding by trends over time in mental health that coincide with but are not caused by the covid19 lockdown third unlike for previously studied countries the danish lockdown was imposed uniformly and rapidly following the first infections and came into effect before the first danish registered covid19 fatality we address these limitations and extend prior work by examining mental wellbeing in denmark a country that imposed a lockdown in march 2020 but reports a substantially lower covid19 burden as of november 30 2020 than does france the us or the uk 18 we also exploit variation in the timing of responses to a nationally representative survey collected in march 2020 on march 11 2020the day the world health organization declared the covid19 outbreak a global pandemic denmark imposed nationwide school closures and the closing of public institutions survey responses occurred immediately before and after the date when the first covid19 lockdown was ordered and imposed in a setup not dissimilar to the one applied by ahrens and colleagues in germany 19 we measured mental wellbeing among the adult danish population through the world health organization five wellbeing index and the work and social adjustment scale these scales capture both preclinical measures of mental disorder as well as impairment further we reinterviewed the sample in july 2020 when covid19 precautions were substantially lessened compared to the lockdown period in march given that previous research on some subgroups finds improved wellbeing following covid19 1920 we specified all tests as twotailed we moreover explored the relation between the lockdown and mental wellbeing by family structure given that stateimposed limitations on social activity may affect persons living alone differently than for persons living with family members as suggested by prior research background lockdown timeline for denmark figure 1 provides a timeline of the danish covid19restrictions the number of confirmed cases for march and start of april 2020 and the data collection window for the first wave of the survey 121 denmark reported its first confirmed sarscov2 case on february 27 2020 1 on march 11 denmark initiated nationwide school closures and the closing of public institutions as the cumulative number of confirmed infections had increased to 264 lockdown measures were further strengthened over the following 6 days to include border closures the closure of restaurants malls and hairdressers and general encouragements to work from home financial aid packages to businesses and furloughed employees were launched in the same sixday period unlike other european countries denmark did not introduce curfews stayhome orders or mandatory use of masks during the spring lockdown the danish government began easing lockdown measures from april 15 2020 lockdown measures were continuously eased over the summer and not reintroduced until september 2020 based on this timeline we defined the beginning of the lockdown measures as march 11 2020 we address the mentioned limitations and extend prior work by examining mental wellbeing in this lowcovid19burden country there are three reasons why we still expect to observe effects of lockdown on mental wellbeing in this context first witnessing critical events such as the growth of a pandemic could impair wellbeing even when the event is not local as when the 911 terrorist attack in the us caused an immediate 16 increase in the incidence rate of traumaand stressorrelated disorders in denmark 22 relatedly ahrens and colleagues argue that physical distancing and lockdowns can be seen as global macrostressors 19 second a recent multicountry study found that people experiencing physical symptoms akin to those symptomatic of covid19 suffer worse mental health implying that perceived impact of the pandemic could also be important 23 and third experiencing even a minor lockdown order could still affect peoples mental wellbeing as lockdown for many implies social isolation and little to no contact with others and as people had to adjust to new daily schedules including homeschooling and working from home methods variables and data to consider how measures of wellbeing and impairment changed following the imposed lockdown we used a representative survey carried out by statistics denmark on behalf of the capital region of denmarks mental health services during marchapril 2020 using a random draw from the present population database of all danish residents aged 18 and above statistics denmark initially contacted 8300 people through personal digital postboxes that are linked directly to peoples unique social security numbers and used for communications between danish residents and governmental institutions all people were contacted at the same time in early march and could respond to the survey when convenient within the survey period respondents answered through computer assisted web interviews with those initially failing to respond receiving prompts by message to their digital postbox the response rate to the first wave of the survey was 34 1127 respondents completed the survey prior to the lockdown announcement and initiation on march 11 and 1709 respondents completed it after march 11 these numbers reflect respondents who provided valid responses to all items of our dependent variables respondents who completed the survey before and after march 11 were generally alike across the background characteristics although the proportion of respondents age 60 decreased and the proportion of respondents with children living at home increased slightly with permission from the capital region of denmarks mental health services we then carried out a follow up survey in july 2020 where the same respondents were reinterviewed again invitations were sent out to everyone at the same time early july and respondents could respond to the survey when convenient throughout the month of respondents participating in the first wave 1526 also participated in the second wave collected in july 2020 for whom we thus have repeated observations younger respondents and respondents with children living at home were less likely to participate in the second wave as were respondents who experienced significant functional impairment in early march but respondents in the second wave generally resemble respondents in early march answers to the survey can be linked at the individual level with administrative data from statistics denmark in addition to survey data on mental wellbeing and functioning our data therefore contain information on age gender living arrangement whether respondents were living with any children in the home region of residence and employment status to capture wellbeing and experienced functional impairment the survey included two validated measuresthe who5 and the wsasthat both have distinct clinically relevant threshold values a review finds that the who5 remains among the most widely used questionnaires assessing subjective psychological wellbeing 24 since its first publication in 1998 the who5 has been translated into more than 30 languages and has been used in research studies all over the world the who5 is a sensitive and specific clinical screening tool for risk of stress and depression that uses five items to capture risk of depression measured between 0 and 100 with each scale contributing 020 points for this measure 0 indicates the most severe depressive symptoms and 100 indicates no symptoms the who5 has strong construct validity as a unidimensional scale 24 for denmark the population norm is established as 70 for adults 25 for the who5 index we used the established cutoff point at 50 to create a binary category for whether a respondent is at risk for depression and stress the wsas is a functional impairment measure designed to measure a patients perceived functional impairment following health problems across five items 26 mundt and colleagues paper of the wsas finds that this instrument is a reliable and valid measure of impaired functioning although not originally intended for nonclinical populations the wsas displays valid psychometric properties across different patient populations that cover both mild and more severe somatic 27 28 29 and mental health 26 30 31 32 conditions furthermore the wsas captures a dimension of impairment distinct from depression 32 although not validated in a danish version it has previously been used both in danish clinical and research settings 30 wsas measures impairment on a scale from 0 to 40 given that we study a nonclinical sample we use the cutoff point at a wsas score of 10 with any score above 10 indicating at least significant functional impairment with or without additional psychopathologies analytical strategy our analytical strategy exploits the fact that data collection took place across the announcement and initiation of lockdown in denmark in march 2020 first we use ordinary least squares linear probability models to compare the outcomes between respondents who answered the survey before and after lockdown began we adjust all models for gender and age and use t tests to evaluate differences between respondents who answered the survey before and after lockdown began next in fully adjusted regression models we control for nuts2region of residence labor market status relationship status and whether respondents had children at home and again use t tests to evaluate the statistical significance of differences between respondents who answered the survey before and after lockdown began the impact of lockdown could differ according to the home environment persons living with family for instance may experience relative more social interaction than would persons not living with family during the imposed lockdown to explore this possibility we performed subsample analyses that compare single individuals to individuals who are living with a partner as well as subsample analyses that compare people living without children in the home to people living with children in the home and test for differences between subgroups using chowtests in addition to fully leverage our data structure with reinterviews in july 2020 we then compared the reported levels of risk of depression and stress and significant functional impairment measured prior to lockdown in march to the levels experienced by the same persons in july accounting for repeated measures of the same individuals with clustered standard errors the latter exercise captures the development in the outcomes across the first wave of covid19 in denmark here we again adjust for control variables in the regression but because we use withinindividual variation across survey waves this inclusion is not essential all calculations were carried out using stata 15mp we then performed several robustness checks first we evaluated whether our choice of thresholds in the outcome variables affect inference second because our sample is not fully identical to the danish population on characteristics such as gender and age we replicate main results using population weights provided by statistics denmark instead of adjusting for variables third selective survey participation across the lockdown in march and across the two survey waves could invalidate our results to address this we use the within person changes in response between march and july as there was very little change in lockdown measures in july all returning respondents recompleted the survey under identical lockdown circumstances if our main pattern of results between respondents who answered prior to and during lockdown in march persist once we take into account individual change up to the postlockdown july wave it would indicate results are robust to differential selection in the first wave of response across the lockdown period and results would thus at least be internally valid fourth the items of the who5 ask respondents to consider their experiences during the preceding 2 weeks to account for the possibility that respondents answering within 2 weeks after lockdown have to consider both time before and after lockdown as a robustness check we weighted answers given in the 2 weeks after lockdown with the amount of time since the lockdown announcement if people considered a full twoweek horizon it would mean that our main estimates of the impact of the lockdown order in march will be biased toward zerothat is our main estimates would be conservative last because our main results focus on respondents with children living at home and because there may be different requirements and worries associated with having children at different ages at home we checked whether results differ by age of the children results table 1 describes the sociodemographic characteristics of the survey participants and the population respondents are similar to the broader danish adult population in terms of geographical region and socioeconomic status we observe some dissimilarities for gender and age which we therefore control for in all reported results over half of participants in the first survey wave in march 2020 completed the survey in july 2020 in addition during the first survey wave 40 completed the survey before the lockdown and 60 completed the survey after the lockdown which permits adequate sample size to estimate mean levels of depressive symptoms and functional impairment during these two distinct periods in march bivariate comparison of our outcomes across the lockdown do not reach conventional levels of statistical detection still adults interviewed after the lockdown in march have a slightly lower prevalence of depression and stress when compared to those interviewed before the lockdown and this finding is statistically detectable when controlling for age and gender yet does not reject the null in the fully adjusted model that controls for additional individual covariates such as household structure if we expand the data to include respondents with valid responses to the who5 items but who had not responded to the wsas the decline becomes statistically detectable functional impairment scores from the wsas also show a slight decline in late march relative to prelockdown but this difference does not reach conventional levels of statistical detection when we control for age and gender following the stateimposed limitations on social activity adults may have relied more on family members for social interaction than they did before the lockdown persons living alone however may have experienced fewer interactions during the lockdown which implies the possibility of heterogeneous impact of the lockdown orders we therefore classified the sample by cohabitation status and then by whether the adult respondent reported children living at home of these subgroups only adults with children living at home show a lower prevalence of depressive symptoms in late march using a chowtest we found that the decrease for adults with children in the home compared to adults without children in the home is larger to statistically detectable degree all other subgroups report no difference in depressive symptoms between early to late march the time course of wsas functional impairment scores largely coheres with that of the subgroup trends for depressive symptoms adults with children living at home show a lower prevalence in functional impairment in late relative to early march again using a chowtest we found that the decrease for adults with children in the home compared to adults without children in the home is larger to statistically detectable degree the lower prevalence of functional impairment among adults with children living at home remains relatively constant across wsas subdomains of work social and home functioning we by contrast find no difference in functional impairment scores among other subgroups when comparing prevs postlockdown periods in march lower panel of fig 2 and additional file 1 lockdown restrictions eased on april 15th we examined whether depressive symptoms and functional impairment differed among respondents several months laterarguably once covidrelated social economic and institutional conventions in denmark stabilized for a while we restricted the study sample to persons who completed the survey in early march and again in july 2020 in aggregate depressive symptoms among these adults fell but functional impairment rose in july relative to early march when disaggregating the july responses by family structure only adults with children living at home and adults in couples reported a reduction in depressive symptoms in july relative to early march by contrast adults with no children at home as well as singles show no change in depressive symptoms over time functional impairment however increased in july for all groups albeit to a much greater extent for adults without children living at home the increase in functional impairment in july among adults with children living at home was much lower the results from our robustness checks do not raise concern over the validity of our main results first modifying the thresholds used to define depressive symptoms and functional impairment did not substantially change results second using statistical weights provided by statistics denmark instead of controlling for covariates did not affect inference third relying on withinindividual differences in the outcomes preand postlockdown in march compared to july answers did not change main results fourth downweighting exposure to the lockdown among respondents who participated on march 12th to 25th as described in the methods section did not affect inference results from our last robustness check shows that our main results for respondents with children living at home are robust across age of the children when focusing on the risk of depression or stress but that the early to late march decrease in the proportion experiencing significant functional impairment is driven by respondents with children older than 6 years discussion existing populationrepresentative estimates of the impact of the covid19 burden on mental wellbeing come from countries with high mortality rates with this study we contribute to the field by providing estimates from denmark which had a comparatively low covid19 burden but imposed a substantial set of societal restrictions we exploit the unique timing of a populationbased behavioral survey to examine whether a covid19 related shutdown preceded an acute change in depressive symptoms and functional impairment contrary to reports in most other countries we find reduced depressive symptoms among adults immediately after the shutdown this result aligns with findings showing a decrease in ptsd symptoms during the first 4 weeks from covid19 outbreak in china 33 and importantly our results also align with results from germany denmarks neighboring country where ahrens and colleagues document significant improvements to mental wellbeing during lockdown 19 last our appear to also be in line with other for denmark although mental wellbeing in that study is observed only after the lockdown from early to late april 34 the reduction we observe moreover concentrates in adults with children living at home measures of functional impairment also decline immediately after the march shutdown but only among adults with children living at home again this finding aligns with results from germany where daily hassles decreased during the first 8 weeks after lockdown likely driven by less commuting and the like 19 findings in denmark indicate that living with children at home may have in the short term buffered the potential mental health sequelae of the covid19 shutdown if others replicate our work strengthening the type of social support that already seems to be present in families may serve as one potential avenue for minimizing the mental health sequelae of extended covid19 shutdowns raabe and colleagues survey of scientists in three european countries coheres with our findings in that they report improved wellbeing immediately after the covid19 lockdown 20 as do results from ahrens and colleagues for one region in germany 19 similarly mari and colleagues find results that mirror ours across residential patterns although they are limited to studying italians during lockdown 16 also tee and colleagues show that some family patterns may reduce the psychological impact of the pandemic in the philippines 35 in contrast a multinational study using data collected late march to early april 2020 generally find that families report the most stress during lockdown 36 but these results may simply reflect differences already existing prior to the pandemic whereas we hesitate to draw populationbased lessons from the select survey of welleducated scientists in raabe et als study 20 the authors note that strong security of employment may have contributed to their shortterm satisfaction with a slower pace and a flexible worklife organization this financial security may be similar to the situation of most danish households during the covid19 pandemic furthermore social cohesion may increase following adverse events given that shared adversity can connect individuals to a broader goal and purpose than before the event 3738 this social cohesion explanation seems consistent with reports of fewer than expected suicide deaths immediately following the first set of covid19 restrictions in germany and japan 3940 we note however that this explanation is necessarily post hoc and requires further refinement and testing before being considered as anything other than informed speculation we also point out that the reductions in depressive symptoms among danes appear confined to adults living with children whereas adults living with children show reduced depressive symptoms in july they are more likely to report significant functional impairment in july we suspect that as they habituate to the reality of a prolonged covid19 pandemic the ability to flexibly balance work family and social expectations may become strained other research also shows that upon returning to workplaces after lockdown the availability of organizational measures to tackle covid19related challenges are associated with less severe psychiatric symptoms which could also explain some of our findings 41 interestingly of any subgroup adults living with children show the lowest rise in significant functional impairment in july 2020 this result should encourage further investigation in both denmark and elsewhere of elements of family life that may benefit social connectivity and general mental health functioning during covid19 strengths of our study include the populationbased nature of the survey the use of two different measures of mental wellbeing and functioning and the fact that survey responses fall immediately before and after the announced lockdown limitations involve the fact that the march comparisons of mental wellbeing before and after the lockdown examine serial crosssections rather than a panel we however controlled for compositional changes of the panel in our analyses the who5 also asks about 14day recall of depressive symptoms which may have biased prevs post march 11 responses towards the null we however controlled for this circumstance using a weighted analysis as a robustness check findings moreover rejected the null which precludes a type ii error also we cannot rule out the possibility of seasonal confounding in that latemarch coincided with spring and better temperature than in early march this seasonal confounding however could only explain the distinct nature of the subgroup responsesin which depressive symptoms and functional impairment fall in latemarch only among adults with children but not among adults living aloneif it affects only adults with children and correlates with covid19related societal restrictions lastly because we only focused on depressive symptoms and functional impairment our study cannot address changes in other mental disorders following covid19related societal restrictions these disorders although strongly correlated with depression warrant further research and may respond distinctively to covid19 related societal restrictions our findings diverge from previous populationbased reports in the uk the us and france this circumstance could arise for several reasons first denmark underwent a much less severe covid19 pandemic in spring 2020 than did these countries as measured by overall cases or deaths per population danes therefore may not have had to contend as heavily with the associated fear and anxiety of covid19related morbidity as did other countries second denmarks strong social safety net largely protects adults and families against large financial shocks that appear more common in other countries when adults lose jobs 42 third the work expectation for adult danes with children when the school closures occurred in march may have been tempered in the short term as a result home life with children may have promoted social interaction and reduced the risk of depression without imposing additional work strain future work may want to explicitly consider these important countrylevel differences when determining what components of the covid19 pandemicthe morbidity the social and educational disruptions the loss of workaffect changes in mental health and wellbeing such work would appear to be critical not only for design of future public health efforts to enhance resilience and recovery but also for development of theory concerned with collective behavioral responses to adversity additional file 2 authors contributions lha pf and tab conceived of the presented idea lha and pf performed the computations lha pf and tab verified the statistical methods lha pf and tab discussed the results and wrote the manuscript and revised the manuscript following peer review the corresponding author confirms that he had full access to all the data in the study and had final responsibility for the decision to submit for publication the authors read and approved the final manuscript consent for publication not applicable competing interests non declared

background existing estimates of the impact of the covid19 burden on mental wellbeing come from countries with high mortality rates this study therefore aimed to investigate the impact of the first covid19 lockdown marchapril 2020 on risk for stressdepression and functional impairment in a representative sample of adult individuals in denmark which had lower infection rates and whether the impact of lockdown was heterogeneous across living situation methods using a representative randomly drawn sample from the complete danish adult population interviewed in march 2 to april 13 2020 n 2836 and again in july 2020 n 1526 54 retention rate we study how the imposed lockdown announced march 11 following the onset of the first danish wave of covid19 infections affected mental wellbeing we use the world health organization five wellbeing index who5 and the work and social adjustment scale wsas to capture risk for stressdepression who5 50 and functional impairment wsas 10 using covariate adjusted ordinary least squares linear probability models and exploiting variation in the timing of responses occurring just before and just after the introduction of lockdown we compare respondents before lockdown to respondents that answered during lockdown as well as to answers in reinterviews in july results in our fully controlled models we find reduced depressive symptoms among adults immediately after the shutdown concentrated in adults with children living at home 089 p 01 from pre lockdown baseline 273 measures of functional impairment also declined immediately after the march shutdown among adults with children living at home 066 p 05 from pre lockdown baseline 150 impairment intensified for the entire sample between march and july 199 p 001 from pre lockdown baseline 248 but depressive symptoms remained at lower rate in july 033 p 05 from pre lockdown baseline 332 conclusions findings in denmark indicate that living with children at home may have in the short term buffered the potential mental health sequelae of the covid19 shutdown

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background considering the benefits of breastfeeding for both infants and mothers the world health organization recommends exclusive breastfeeding for the first 6 months of life and introduction of nutritionallyadequate and safe complementary foods at 6 months together with continued breastfeeding up to 2 years of age or beyond 1 however inequity has been found between different countries as well as within certain countries 2 as a member of who china launched the national nutrition plan aiming to increase the ebf rate to at least 50 by 2020 nevertheless several studies conducted nationwide demonstrated suboptimal outcomes 34 the weighted prevalence of ever breastfeeding exclusive breastfeeding among all infants under 6 months of age breastfeeding at 1 year of age and breastfeeding at 2 years of age were 796 208 115 and 69 respectively in 2013 3 breastfeeding practices are predicted by demographic factors healthrelated factors social support and policies 5 however few studies have examined the potential influence of ruraltourban migration on breastfeeding practices according to some studies ruraltourban migrant population are more vulnerable to healthrelated issues such as unhealthy lifestyle 6 low rate of medical treatment seeking behaviors 78 and deficient disease management 9 an increase of ruraltourban migrant population in china has been noticed since 2000 and it is expected to reach nearly 300 million before 2020 1011 many infants and children have also moved into cities with their parents for better healthrelated services and education studies about the association between breastfeeding practices and residence inconsistency mainly focused on migrants who are living or giving birth in foreign countries 12 13 14 15 16 these studies all concluded that the prevalence of breastfeeding practices was different between migrants and local people to our knowledge there are few studies focusing on breastfeeding practices among ruraltourban migrant children in china considering the sensitivity of ruraltourban migrants to health issues it is reasonable to assume that there are differences in breastfeeding practices between ruraltourban migrant children and local children methods study design and participants a crosssectional survey was conducted among children aged under 12 months in mainland china in 2018 which was described in detail below their caregivers were interviewed about breastfeeding practices and potential determinants facetoface multistage stratified cluster random sampling was used in the study all countiesdistricts in 31 provincesautonomous regionsmunicipalities in china were categorized into four strata metropolis medium and small cities general rural areas and poor rural areas based on the population within 1 year of the national notifiable disease report system in 2014 probability proportional to size sampling was used to select counties from each stratum after considering geographic distribution 12 counties were chosen in the study in each selected county four townships or communities were pps sampled and additional sampling was conducted from adjacent county if the number of communities was less than four in some medium and small cities finally in each selected township 70 children from each monthage group were randomly selected according to list of children in the expanded program on immunization in metropolis and medium and small cities household registered children and migrant children whose mothers migrated from other counties for more than 1 month were sampled in the same proportion the total sample size was 9760 for children under 1 year of which 6995 was for children from metropolis and medium and small cities sample size calculation was based on the ebf rate according to the chinese residents nutrition and health survey in 2013 and complex sampling design was considered measurements uniformly trained investigators collected data by facetoface interviews using smartphonepadbased questionnaires to record response all the questionnaires were thoroughly checked up for omissions or errors and corrected during the interview quality control staffs from the provincial cdcs checked these questionnaires for another time maternal ruraltourban migrant status was the primary variable in this study considering that ruraltourban migrants were mainly found in cities we excluded participants from the rural areas in this paper in the baseline survey mothers were asked about their current place of residence and time of residence the place of residence was classified into six categories including nonhousehold registration residence at province level nonhousehold registration residence at city level nonhousehold registration residence at county level nonhousehold registration residence at village level household registration residence and others the duration of residence was classified into three categories including less than 1 month 1 to 5 months and more than half a year in this study ruraltourban migrant was defined as migrating from the household registration residence at county level or above for more than 1 month according to the definition from national health and family planning commission 17 those who migrated for less than a month were excluded in our study due to their unstable residence status the outcome variables in this study were ever breastfeeding exclusive breastfeeding under 6 months predominant breastfeeding under 6 months and ageappropriate breastfeeding these breastfeeding practices were assessed based on the world health organization indicators for assessing infant and young child feeding practices 18 the calculation of ebf and predominant breastfeeding was conducted among infants aged under 6 months exclusive breastfeeding was defined as breast milk was the only food and liquid consumed with the exception of oral rehydration salt drops and syrups using a 24h recall questionnaire predominant breastfeeding was defined as proportion of infants aged under 6 months who received both breast milk and other fluids but not milk or solid foods during the previous day for ever breastfeeding and ageappropriate breastfeeding prevalence the calculation was conducted among children aged from 0 to 12 months ever breastfeeding was defined as proportion of children born in the last 12 months who were ever breastfed ageappropriate breastfeeding prevalence was calculated using the sum of infants aged under 6 months who were exclusively breastfed during the previous day and children aged 612 months who received breast milk with solid semisolid or soft foods during the previous day divided by the total number of children aged 012 months sociodemographic characteristics were grouped into two categories mothers and infants mothers sociodemographic characteristics included maternal age maternal ethnicity maternal bodymass index maternal education level maternal employment and maternal residence those of infants were infant sex infant birthweight delivery method and preterm birth health information included maternal illness during pregnancy and infants illness within 2 weeks after birth according to the mothers selfreported questionnaire they were considered not ill during pregnancy unless theyve had gestational diabetes mellitus or hypertensive disorder complication pregnancy or postpartum hemorrhage infants was considered ill within 2 weeks after birth if they had one of neonatal hospitalization neonatal hypoglycemia neonatal jaundice diarrhea within 2 weeks after birth and respiratory diseases within 2 weeks after birth otherwise they were considered healthy within 2 weeks after birth supportive information were those covariates related to knowledge experience and support to breastfeeding including maternal breastfeeding history maternal knowledge about benefits of breastfeeding parents supported breastfeeding parentsinlaw supported breastfeeding husband supported breastfeeding and best friend supported breastfeeding maternal knowledge about benefits of breastfeeding was measured using a 11items multiplechoice question and categorized into two groups above upper quantile and below upper quantile mothers were asked about their families and best friends attitude about breast milk and infant formula milk they were considered supporting breastfeeding only if they thought breast milk was much better than formula milk otherwise they were not considered supporting breastfeeding data analysis pairwise deletion was used to handle missing data in statistical descriptions or univariate analysis in multivariable analyses we used listwise deletion for variables with 10 missing data and assigned a category unknown to the missing value of categorial variables with ≥10 missing data and did not excluded these cases descriptive analysis was used to illustrate the basic sociodemographic characteristics in different maternal ruraltourban migrant groups the independent ttest and χ 2 test were used to compare the distributions of sociodemographic characteristics according to different migrant status as appropriate the prevalence of breastfeeding practices was compared according to maternal ruraltourban migrant status and pearson χ 2 test was used to test the significance the associations between maternal ruraltourban migrant status and breastfeeding outcomes were analyzed using logistic regression model fitted unadjusted adjusted for motherinfant sociodemographic characteristics additionally adjusted for motherinfant health information further adjusted for supportive information to further understand the relationship between maternal ruraltourban migrant status and their breastfeeding practices we stratified them into different groups using their education level place of residence and ethnicity respectively and logistic regression models mentioned above were conducted according to these stratifications in this step to simplify the stratification maternal education level was further categorized into three groups high including college and above mid including senior high school low including junior high school and below which were compulsory education in china a stepwise backward elimination procedure was carried out in the regression model and the odds ratios were presented with 95 confidence interval all of the analyses were done with r 360 and spss 240 twosided p values of less than 005 were deemed to be statistically significant results table 1 shows the sociodemographic characteristics of mothers and infants by maternal ruraltourban migrant status of all 6995 participants from metropolis and medium sized or small cities 6896 mothers were included in our study 4381 of them were local population and 2565 were ruraltourban migrants the mean maternal age of ruraltourban migrants was significantly smaller than that of local population 2905 the distributions of infant birthweight infant sex maternal education and preterm birth were similar between local people and migrants as for occupation after conducting a posthoc test we found migrant mothers were less likely to get formal employment local mothers were more likely to be han ethnic living in medium sized or small cities and having vaginal deliveries as shown in table 2 the overall prevalence of ever breastfeeding ebf predominant breastfeeding and ageappropriate breastfeeding were 9751 2984 5989 and 4507 respectively compared to local people the prevalence of breastfeeding practices of ruraltourban migrants were slightly but not significantly lower however significant differences were found in ever breastfeeding and ebf between the two groups after adjusting for motherinfant sociodemographic characteristics and motherinfant health information however only ebf was still significantly less among migrants when further adjusted for mothers who received supportive information no significant differences were found in other two breastfeeding practices table 3 shows the relationships between ruraltourban migrant status and ebf stratified by maternal education level place of residence and maternal ethnicity respectively in the stratification of maternal education level the overall prevalence of ebf was not significantly different between ruraltourban migrants and local people in both groups however after adjusting for other variables ruraltourban migrants showed lower ebf rate than local people merely in the group with high education level referring to the stratification of place of residence significantly lower ebf rate in ruraltourban migrants was only noticed among those living in metropolis stratified by maternal ethnicity ruraltourban migrant children of minority mothers were considerably less exclusively breastfed than local children of minority mothers discussion this is the first study to describe prevalence of breastfeeding practices among ruraltourban migrants and examine the association between them based on a large populationbased sampling survey the findings in this article are highly reliable and meaningful in the present study the prevalence of breastfeeding practices was not optimal to meet the goal by 2020 the ruraltourban migration was only inversely related to ebf among those with high education level living in metropolis and being minority after adjusting for other covariates prevalence of breastfeeding practices the overall prevalence of breastfeeding practices found in this study is too low to meet the goal about 50 ebf rate in 2020 recent study showed that only 37 of children younger than 6 months of age were exclusively breastfed in lowincome and middleincome countries prevalence and odds ratios for ebf and predominant breastfeeding were calculated among infants aged under 6 months 2 higher than what we found in this study chinese used to have a good tradition of breastfeeding and more than 80 mothers breastfed their children 19 but since 1970s the prevalence of breastfeeding has dropped dramatically 320 there is urgent need for promotion methods like personal sessions family education and social support to increase breastfeeding rate in china especially ebf rate 21 22 23 association between breastfeeding practices and ruraltourban migration in the present study we found that prevalence of the four breastfeeding practices in ruraltourban migrants was slightly but not significantly lower than that of local population ruraltourban migrants are more vulnerable to healthrelated issues because most health services and policies are registrationrelated in china making those migrants inconvenient to have access to them however breastfeeding is more complicated than those traditional health issues it also takes consideration of selfefficacy and social environment 23 24 25 some studies concluded that maternal education was a strong indicator for breastfeeding practices 26 we found no difference in maternal education between the two groups of participants which could reduce the difference in breastfeeding practices between them babyfriendly hospital practices may also help the establishment of breastfeeding 27 particularly giving only breast milk in the hospital 28 as the new medicare reform involved more registrationinconsistent people ruraltourban migrants can have similar even the same access to hospital services like local citizens resulting in similar prevalence of breastfeeding practices in the two groups after adjusting for other confounding variables ruraltourban migrant status was solely significantly and robustly associated with exclusive breastfeeding this indicates the association between ruraltourban migrant status and ebf may be modified by other variates in another study conducted in 2013 in china they examined the association between maternal migrant status and ebf and found it not significant 4 however the definition of maternal migrant status was not described in the study and no further multivariate analysis was conducted between them we found no other study discussing the association between ruraltourban migrant status and breastfeeding practices in china according to previous studies maternal education level place of residence and maternal ethnicity were three main factors that associated with breastfeeding prevalence 29 stratified by those three factors we noticed some special vulnerable groups which should be paid more attention to about exclusive breastfeeding migrants with high education level gave less exclusive breastfeeding to their children than local mothers with the same diploma however such difference was not found within those with low education level the association between maternal education level and ebf remains inconsistent according to the systematic review of boccolini et al the low education level was associated with the interruption of ebf in brazil 29 however another systematic review of zhao j et al found that in the chinese culture and employment environment mother with higher education level were less likely to breastfeed their babies compared to those who were less educated 26 among higher educated mothers in our study ruraltourban migrant status became a risk factor for ebf and we presumed that it was caused by their working status and living places migrants are more likely to rent a house rather than buying one without enough space for breastfeeding especially in suburb areas higher educated migrant mothers may have better jobs equivalent to their diploma in central areas and hire babysitters to looking after their children as migrants they may face more pressure than the adjusted variables are the same variables adjusted in the model c table 2 b 1 case with missing data of maternal education level local citizens and have to work hard to avoid being fired and earn enough money for rental and baby caring thus they may have difficulties balancing work and child care and reducing their time with children 3031 the long distance between their rent house and working place also reduced their time for breastfeeding migrants with lower education level may just find jobs near their living place for convenience and most of them may be informal employed which means they have less traffic time and face less pressure than higher educated ones 32 the low ebf rate of lower educated participants itself may also lighten the influence of ruraltourban migration on exclusive breastfeeding place of residence is another factor that affects the association between ruraltourban migration and exclusive breastfeeding overall living in metropolis rather than medium sized or small cities can promote exclusive breastfeeding super cities like capitals can provide more healthrelated services prenatal lessons and peer education to highlight the importance of exclusive breastfeeding 33 in the subgroup of participants living in metropolis ruraltourban migrant children are less likely to be exclusively breastfed than local ones the expense of living in metropolis is much higher for migrants and they are more common to have mental health problems than natives 34 when local citizens are surrounded by plenty resources of postpartum and neonatal caring the migrants may be facing heavy working load or traffic jam resulting in less time for breastfeeding high prevalence of postpartum mental health problems in migrants can also deter the execution of exclusive breastfeeding 35 duration of residence can also affect breastfeeding practices a study conducted in hong kong revealed that breastfeeding duration was progressively shorter when the immigrant time increased 14 however the difference of ebf rate between ruraltourban migrants and local people living in medium sized or small cities is slight but not significant the scale of the cities is not as big as metropolis and the traffic congestion is not so severe so these migrants waste less time in commuting and have enough time for breastfeeding also migrants living in medium sized or small cities face less stress of living and working than those in big cities and they are less vulnerable to postpartum mental health problems the lower prevalence of ebf in ruraltourban migrants was solely apparent in ethnic minorities this result is consistent with previous findings fenglian xu et al conducted a survey in xinjiang china 2004 and concluded that ebf rate in the han was significantly lower than other minority 36 there was only 1 uygur participant in our study making our minority similar to other minority in xus article another study in china 2014 also found ethnic han was associated with decreased likelihood of exclusive breastfeeding 37 acculturation to the culture of not favoring breastfeeding can reduce the prevalence of exclusive breastfeeding 38 we postulated that migrants were likely to abandon their traditional breastfeeding practice and adopt hans disfavor of breastfeeding 3739 local minority citizens are more likely to live in ethnic communities and maintain their traditional breastfeeding habits 40 however it might be hard for minority migrants to fit into such ethnic communities resulting in loss of their traditional breastfeeding practices there are still some limitations in our study first we didnt consider the original registration place for migrant population specifically where they are from may largely affect their employment status then make difference to their practice of breastfeeding second causal effect between ruraltourban migrant status and ebf was difficult to examine because of the nature of crosssectional study further perspective study is needed to clarify the causal relationship third the prevalence of breastfeeding practices was calculated based on a 24hour recall method which could overestimate the prevalence and cause recall bias conclusions a large proportion of infants were not exclusively breastfed in both local and ruraltourban migrant population the prevalence of breastfeeding practices was lower than the who recommendation and the target of chinese national nutrition plan this study has indicated ruraltourban migrant status is a risk factor for mothers to practice exclusive breastfeeding the association between migrant status and prevalence of ebf varied across maternal education level place of residence and maternal ethnicity besides common strategies special approaches should be provided for those vulnerable groups abbreviations bmi body mass index ebf exclusive breastfeeding who world health organization funding the study was supported by the china development research foundation and bill gates foundation competing interests the authors declare that they have no competing interests

background in china less than one third of infants under 6 months of age are being exclusively breastfed maternal ruraltourban migration contributes to these low rates of breastfeeding practices therefore the aim of this study was to assess the prevalence of breastfeeding practices and associated factors among ruraltourban migrant children and local children with infants aged 012 months in china 2018 methods data were collected from a populationbased crosssectional survey in 2018 that included 6995 infants from eight urban areas four metropolis and four medium sizedsmall cities in china the prevalence of breastfeeding practices was calculated using a 24h recall questionnaire for all infants aged under 12 months logistic regression was conducted to examine the association between the prevalence of breastfeeding practices and maternal migrant status after adjusting for sociodemographic characteristics motherinfant health information and supportive information for exclusive breastfeeding we further analyzed its association with maternal ruraltourban migration stratified by maternal education level maternal resident place and maternal ethnicity respectively results the overall prevalence of ever breastfeeding exclusive breastfeeding predominant breastfeeding and ageappropriate breastfeeding exclusive breastfeeding of infants under 6 months of age and complementary feeding from six to 12 months of age was 9751 2984 5989 and 4507 respectively ruraltourban migrant children were less likely to be exclusively breastfed compared to local children aor 081 95 ci 068 095 stratified by different sociodemographic variables a negative association between exclusive breastfeeding and ruraltourban migration was only found in the group with high education level in the group living in metropolis and in the group of minorities respectively conclusions the overall prevalence of breastfeeding practices was low in both ruraltourban migrant children and local children besides common strategies special approaches should be provided for urban highly educated migrants

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background since the coronavirus disease 2019 pandemic began perinatal women have experienced psychological stress due to changes in labor and delivery hospital policies 1 possible perinatal covid19 transmission 2 and covid19 clinical maternalinfant outcomes 3 these perinatalrelated stressors are in addition to the economic and mental health issues that many people are currently experiencing while stressors for perinatal women can be found worldwide pregnant women in the united states have the highest maternal mortality rate in the developed world and social and environmental stressors contribute to a womans risk of dying within 1 year of pregnancy 4 our previous research demonstrated higher levels of anxiety and depression in american pregnant women compared to dutch 5 pregnant women and higher levels of psychological stress compared to british pregnant women 6 psychological stress experienced during pregnancy can have deleterious effects on maternal and infant health 7 where the pathway between stress and physiological issues involves cortisol norepinephrine and inflammatory markers including cytokines 78 the health ramifications due to perinatal stress not only impact the mother but also may harm the fetus and infant for example elevated glucocorticoids during fetal development are associated with a higher likelihood of adverse birth outcomes and predisposition to obesity and other lateonset diseases 9 in addition effects of prenatal stress on offspring neurodevelopment cognitive development negative affectivity difficult temperament and psychiatric disorders have been demonstrated in numerous epidemiological and casecontrol studies 10 the american college of obstetricians and gynecologists has acknowledged the impact of psychological stress on infant and maternal health and therefore recommends perinatal screening and intervention for stress for all pregnant women 11 the assessment of coping is crucial to understand the ways in which psychological stress and stressful life events can be buffered 12 13 14 15 with the adaptative value of coping stemming from being able to control the stressor or relying on support from others in addition sociocultural contexts have to be considered in the study of perinatal stress and coping 16 as effects of psychosocial stress experienced during pregnancy can also vary by race ethnicity and socioeconomic status 1718 for example there are increased incidences of adverse birth outcomes including higher infant mortality rates fetal mortality rates and preterm birth in african americanblack and latino women compared to european americans 19 20 21 in addition women in lower socioeconomic groups have an increased risk for stress and pregnancy complications that are independent of other factors 22 while research on stress and coping of perinatal women during the covid19 pandemic has yet to be published reports on pregnant women in china indicate that the covid19 pandemic may increase the risk for mental illness 23 and research with pregnant women in the united states demonstrate elevated levels of anxiety and stress 24 particularly in vulnerable groups 25 therefore we assessed stressors coping behaviors and resources needed in relation to the covid19 pandemic in a sample of perinatal women in the united states using a concurrent mixed methods study design methods measures demographic information included age race ethnicity pregnancy status and location of residence health insurance employment income and education information was also collected as informed by the coronavirus health impact survey v01 adult selfreport baseline form 27 survey items were selected from the centers for disease control and prevention covid19 community survey question bank form 28 general impacts of covid19 including financial and other areas of stress were measured using multiple selection items women were asked to cope with social distancing isolation or stress related to covid19 are you doing any of the following and were provided a list of coping behaviors women were also asked to report recent financial impacts including serious financial problems incomepay reduction being laid off or furloughed by employer having a household member lose their job etc survey items pertaining to covid19 diagnosis and medical history were informed by the coronavirus health impact survey v01 adult selfreport baseline form 27 women were asked if they had received a covid19 diagnosis for self family member inside household or family member outside household pregnancy and postpartum information were also collected changes to prenatal healthcare behaviors due to covid19 were measured using a checklist of common experiences women were also asked to select reasons for difficulty in obtaining healthy foods to support pregnancy financial hardship scarcity and shelter in place restrictions items relating to pregnancyspecific behaviors were given only to the pregnant participants as postpartum participants could have entered the study pregnant prepandemic and postpartum only during the pandemic a subset of perinatal women responded to three openended questions regarding stressors and resources needed during the covid19 pandemic social support was then assessed using the interpersonal support evaluation list short form a 12item measure of three dimensions appraisal support belonging support and tangible support 29 each dimension is measured by four items on a 4point scale ranging from definitely true to definitely false with higher scores indicating more social support scores on the total isel and each subscale were normally distributed based on skewness and kurtosis statistics each isel subscale was statistically significantly related to the total isel score cronbachs alpha indicated that the total isel score and each subscale was internally consistent for our perinatal sample please refer to the additional file 1 for the openended qualitative questions and survey items study design a concurrent mixedmethods study design using cluster sampling of perinatal women in the united states was used to capture quantitative responses on stressand copingrelated survey items and qualitative responses to openended questions regarding stressors and resources needed during the covid19 pandemic both types of responses were analyzed concurrently and data was mixed after quantitative and qualitative analyses were completed capturing both survey and qualitative responses provided a comprehensive assessment of stressors coping and needs of perinatal women during the covid19 pandemic please refer to the supplementary table for the consolidated criteria for reporting qualitative studies 32item checklist the survey took participants 10 min on average to complete the isel and three openended questions took participants and additional 15 min on average to complete this study was deemed exempt by washington state universitys institutional review board statistical analysis descriptive statistics are reported for pregnant and postpartum women separately mean and standard deviations are presented for continuous variables and the percent of participants endorsing each category is reported for categorical variables logistic regression and linear regression were used to compare responses across pregnant vs postpartum women controlling for age income statefederallyfunded insurance and raceethnicity odds ratios 95 confidence intervals and pvalues are reported for logistic regression results and standardized regression coefficients and pvalues are reported for linear regression results p ≤ 05 was used to indicate statistical significance all analyses were conducted in spss version 26 content analysis qualitative content analysis 30 field notes were taken at coder analytic meetings and at the various iterations of coding conducted to reduce the data into themes for each response themes were generated for the words and phrases expressed by the respondents themes were then coded using a set of mutually exclusive categories we then assessed frequency of each concept conceptual content analysis was completed by two coders and then verified by a third coder any discrepancies in theme development list of concepts or concept coding were discussed among the coders and the final coding was reached via consensus data saturation was discussed with the coding team upon first meeting to discuss data coding all coders agreed that saturation was reached based on frequency of consistent data supporting each theme with no new data offering additional unique information qualitative data was managed in spss version 26 results participant characteristics participants were 162 pregnant or postpartum women women aged 1945 years 79 nonhispanic white 7 hispaniclatino 5 black 4 asian and 5 more than one race ninetysix percent of the sample were employed homemaker or a student 96 were covered by health insurance 19 had statefederallyfunded insurance and 56 had a total household income ≥ 75000year thirtynine percent of pregnant women had no children in their household with the remaining participants reporting 14 children in their household postpartum women had a range of 15 children in their household no participants were positive for covd19 one participant had a family member test positive for covid19 the subset of perinatal participants that was given additional items related to social support stressors and resources needed included 79 women women aged 2342 years 88 nonhispanic white 8 hispaniclatino 1 asian and 3 more than one race all participants in the subsample were employed homemaker or a student 99 were covered by health insurance 8 had statefederallyfunded insurance and 72 had a total household income ≥ 75000year fiftyseven percent of pregnant women had no children in their household with the remaining participants reporting 13 children in their household postpartum women had a range of 15 children in their household prevalence of stressors and coping behaviors please refer to table 1 for prevalence of individual stressors and coping behaviors reported by perinatal participants during the covid19 pandemic 27 of pregnant women reported inability to obtain healthy food sixteen percent of pregnant participants reported that shelterinplace restrictions impacted their access to healthy foods whereas 7 reported financial hardship as the reason they were unable to obtain healthy foods while 25 of the participants missed prenatal appointments 36 reported using telemedicine for prenatal appointments and about half talked to their provider about labor and delivery and covid19 fortysix percent of the sample sought additional information about how covid19 was impacting the hospital where they planned to deliver or had delivered in terms of financial stressors 19 of participants had incomepay reduced 9 were laid offfurloughed and 10 had another household member lose a job ten percent reported serious financial problems and 19 had difficulty arranging childcare to cope with social distancing isolation or stress related to the covid19 pandemic 69 took breaks from news outlets and 62 engaged in healthy behaviors like trying to eat healthy exercising getting plenty of sleep and avoiding alcohol and drugs fiftyfive percent of participants connected with others to cope with social distancing isolation and stress during the pandemic and 59 made time to relax regression analyses pregnancy and parenthood differences after accounting for demographic covariates pregnant women were less likely to engage in healthy stresscoping behaviors than postpartum women such as taking breaks from watching the news trying to eat healthy exercise etc making time to relax and connecting with others the results are found in table 2 demographic disparities women of color and women with lower incomes were more likely to report serious financial problems compared to nonhispanic white women and women with higher incomes women with lower incomes were also less likely to includes all women who identified as hispanic black asian or multiple races engage in healthy stresscoping behaviors compared to women with higher incomes such as taking care of their bodies and connecting with others during the pandemic while mean scores on the isel and isel subscales indicated high levels of social support disparities also existed for interpersonal support women with higher incomes not on medicaid and nonhispanic white women reported higher iseltotal scores compared to women with lower incomes women on medicaid and women of color respectively the same pattern of results was found for iselappraisal support women with higher incomes not on medicaid and nonhispanic white women reported higher iselappraisal support compared to women with lower incomes women on medicaid and women of color nonhispanic white women also reported higher iselbelonging support and iseltangible support compared to women of color qualitative content analysis content analysis codes and response rates along with exemplar quotes describing the codes are presented in table 4 primary stressors participants reported being most worried about their baby contracting covid19 with 52 pregnant and 49 postpartum women reporting this concern this was followed by their concern of self or partners contracting covid19 i had a csection and during that time i was worried that if i caught covid my immune system wouldnt be able to cope i was afraid to die and leave my baby behind 126 postpartum these concerns were almost always connected to one another as depicted here as this participant notes their greatest concern during the pandemic me or my husband contracting the virus and giving it to our newborn 162 postpartum participants were also concerned about isolating from their baby should they or their infant test positive for covid19 other concerns noted were family missing key obstetric appointments and events lack of social support their baby entering a new world and finances and resources im worried that my husband and i wont have enough money to support our baby 97 pregnant items and resources lacking that are causing stress participants noted they were lacking cleaning and baby supplies i have had a hard time getting diapers formula wipes and other nursingpumping supplies 137 postpartum as reported in the other qualitative codes financial needs social support and childcare were also stated as lacking during the covid19 pandemic and these were often described together as reported here support groups finances support from work to care for child safe childcare options or longer time to stay at home with child 134 postpartum resources needed participants indicated that the primary resources they needed were information regarding covid19 and access to healthcare this was often related to the need for social support online support groupchat for new parents in this time 113 postpartum financial assistance access to groceries and supplies workplace needs and childcare were also noted fair access to diapers wipes cleaning supplies 106 pregnant updated list of in stock items available on store websites 153 postpartum discussion our study found that food scarcity and shelter in place restrictions as a result of the covid19 pandemic have made it difficult for pregnant women to find healthy foods the stress resulting from food scarcity implicates acutelyresponsive systems like stress physiology while also impacting intergenerational effects of the mothers chronic nutrition adversity on offspring development 31 financial issues were also prevalent in our sample and participants had difficulty obtaining childcare our qualitative results support the survey findings as financial resources and access to healthcare were primary concerns and resources needed by participants while participants reported missing prenatal appointments many also reported using telemedicine for prenatal appointments and talked to their provider about labor and delivery and covid19 this stressor corresponds with recent research indicating that pregnant women experienced elevated levels of stress related to feeling unprepared for birth during the pandemic 2425 telemedicine is a useful resource for perinatal women during the pandemic as it decreases waiting times and risk of infection by greatly limiting inperson clinic visits patient education regarding the use of this video service and following best practices for telemedicine will aid in decreasing patient stress unfortunately there are barriers to the access of telemedicine as it may be difficult for patients to be connected to these services in remote or rural areas additionally healthcare providers should acknowledge that not all perinatal women own or have access the necessary equipment to support video calls and the lack of resources can be a burden on womens access to essential care 32 to cope with social distancing isolation and stress during the pandemic participants took breaks from news outlets engaged in healthy behaviors such as trying to eat healthy exercising getting plenty of sleep avoiding alcohol and drugs connecting with others and making time to relax however pregnant women were less likely to engage in these healthy stresscoping behaviors than postpartum women it may be that pregnant women are less likely to engage in healthy stress coping behaviors because they are focused on selfisolating due to concerns about contracting covid19 and being separated from their newborn after delivery compared to postpartum women conversely postpartum women may feel more connected with others once their baby is born and attention may shift to caring for their baby versus stress about covidrelated what ifs our qualitative results elaborate on these findings as many pregnant women expressed concerns about their baby contracting covid19 while in the hospital and significant others missing the delivery or key ob appointments and wanting support from friends family and birthing classes our findings further corroborate recent research that indicates that there is high prevalence of stressors related to perinatal covid19 infection in pregnant women 2425 additional research is needed to further explore differences in stressors and coping behaviors between pregnant and postpartum women while our sample was predominantly nonhispanic white we were able to detect signals of greater stress induced by the covid19 pandemic and less social support in perinatal women of racial and ethnic minority and lowerincome status women of color and women with lower incomes were more likely to report serious financial problems compared to nonhispanic white women and women with higher incomes women with lower incomes were also less likely to engage in healthy stresscoping behaviors compared to women with higher incomes women with higher incomes not on medicaid and nonhispanic white women reported more social support compared to women with lower incomes women on medicaid and women of color these differences highlight the need to examine the sociocultural contexts of psychological adaptation to perinatal stress and coping 16 17 18 which may be exacerbated during the covid19 pandemic this is also in line with previous research noting women in lower socioeconomic groups have an increased risk for stress and pregnancy complications 22 recent research indicating that women of color experienced elevated levels of stress related to feeling unprepared for birth or being worried about perinatal infection 25 pandemicrelated stress experienced by perinatal women underscore the need to mitigate the downstream adverse impacts of the covid19 pandemic on maternalinfant health in particular women in lower socioeconomic groups and women of color may have increased stress and stressors and fewer resources to cope with their stress adding to the disparity in covid19 diagnoses hospitalization clinical outcomes and mortality 33 34 35 36 assessing perinatal stress and isolation as it relates to the covid19 pandemic and increasing access to psychological services via telehealth may be useful in preventing negative maternalinfant outcomes early mental health interventions may help lower the risk of postpartum depression and help promote the longterm wellbeing of mother and baby 37 additional resources that may help alleviate stress include assurance of safe access to healthcare access to groceries and supplies online social support via parenting groups and financial assistance limitations include the crosssectional design and nationwide response which presents a single snapshot of stressors and coping of american perinatal women during the covid19 pandemic we expect that stress and coping may fluctuate depending on shelterinplace orders rates of covid19 confirmed cases hospitalizations and deaths and access to crucial resources in local communities in addition while some counties have been in a phase 1 shelterinplace for over 6 months some states have not placed any restrictions on residents however research on stress and coping of perinatal women during the covid19 pandemic is critically needed as research with pregnant women in china demonstrate a risk for mental illness during the pandemic 23 and research with pregnant women in the united states demonstrate elevated levels of anxiety and stress in this population 2425 therefore our crosssectional report of stressors coping behaviors social support and resources needed in relation to the covid19 pandemic in a sample of perinatal women in the united states extends current literature by assessing social support and resources needed using a qualitative approach to describe the patient perspective and including postpartum women this offers healthcare providers additional insight needed to mitigate psychological stress that can have important effects on maternal and infant health 7 future research should assess partner support and psychological services used during pregnancy and postpartum as early mental health interventions may help promote wellbeing of mother and baby 37 in summary we identified key stressors affecting perinatal women during the covid19 epidemic our study identifies several key messages relevant for healthcare providers healthcare providers should familiarize themselves with local services near their clinics and hospitals to better assist perinatal women in finding resources in their community some services that should be offered include food banks women infant and children nutrition program and assistance with formula diapers and other supplies patient education about how to cope with stress may be an effective way to help perinatal women engage in healthier options at home healthcare providers should engage in conversations regarding the burden of finding childcare when schools and daycares are closed and continue asking women if their kids feel safe at home and how the loss of school resources has impacted their family these questions will help assess the support and resources that perinatal women may need accommodations should be made for those who cannot participate in telemedicine due to lack of access or language barriers for example women in lower socioeconomic groups and rural residents may not have consistent access to the internet to better support perinatal womens mental health healthcare providers should refer patients to counseling services virtual support groups and consistently screen pregnant women for depression and anxiety conclusion psychological stress experienced during pregnancy can have important effects on maternal and infant health we assessed stressors coping behaviors and resources needed during the covid19 pandemic in a sample of perinatal women in the united states we identified a myriad of stressors from financial issues difficulties finding healthy food to missing healthcare appointments importantly we observed that pregnant women were less likely to engage in healthy stresscoping behaviors than postpartum women lastly we were able to detect signals of greater stress induced by the covid19 pandemic and less social support in perinatal women with racial and ethnic minority and lowerincome status qualitative results support our survey findings as participants expressed concerns about their baby contracting covid19 while in the hospital significant others missing the delivery or key ob appointments and wanting support from friends family and birthing classes our findings are relevant for current providers and will help to inform interventions to mitigate stressors in this vulnerable population competing interests the authors declare that they have no competing interests

background psychological stress and coping experienced during pregnancy can have important effects on maternal and infant health which can also vary by race ethnicity and socioeconomic status therefore we assessed stressors coping behaviors and resources needed in relation to the covid19 pandemic in a sample of 162 perinatal 125 pregnant and 37 postpartum women in the united states methods a mixedmethods study captured quantitative responses regarding stressors and coping along with qualitative responses to openended questions regarding stress and resources needed during the covid19 pandemic logistic and linear regression models were used to analyze differences between pregnant and postpartum participants as well as differences across key demographic variables qualitative content analysis was used to analyze openended questions results during the covidpandemic food scarcity and shelterinplace restrictions made it difficult for pregnant women to find healthy foods participants also reported missing prenatal appointments though many reported using telemedicine to obtain these services financial issues were prevalent in our sample and participants had difficulty obtaining childcare after controlling for demographic variables pregnant women were less likely to engage in healthy stresscoping behaviors than postpartum women lastly we were able to detect signals of increased stressors induced by the covid19 pandemic and less social support in perinatal women of racial and ethnic minority and lowerincome status qualitative results support our survey findings as participants expressed concerns about their baby contracting covid19 while in the hospital significant others missing the delivery or key obstetric appointments and wanting support from friends family and birthing classes financial resources covid19 information and research as it relates to maternalinfant health outcomes access to safe healthcare and access to baby supplies formula diapers etc emerged as the primary resources needed by participants conclusions to better support perinatal womens mental health during the covid19 pandemic healthcare providers should engage in conversations regarding access to resources needed to care for newborns refer patients to counseling services which can be delivered onlinevia telephone and virtual support groups and consistently screen pregnant women for stressors

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introduction 1definition and history of coparenting research over the past few decades the coparenting relationship has become a prominent area of study with scholars and practitioners alike debating the determinants of relationship quality as well as how individuals can play a crucial role in building and maintaining strong coparenting partnerships as family systems theory posits the whole family system encompasses interrelated subsystems in which family members interact in ways that cannot be fully understood by looking at dyadic relationships alone 1 acting as two managers with full agency responsible for parenting activities parents need to acknowledge and respect the others practice during contingencies and crises of parenthood accompanied by likely tensions and frustrations 23 one definition of coparenting acknowledges coparents as at least two individuals who share childrearing responsibilities upon mutual agreement 2 the practice involves parents children 2023 10 1884 2 of 23 joint cooperation that divides childrearing duties including instrumental support and emotional support after the birth of a child some of the first empirical studies focus on triadic family relations which examined parental interaction in analyses of the frequency and intensity of parents supportive or undermining behaviors of each other as well as how parents negotiate and strategize coparenting 45 built upon these observations consequent studies identified three major conceptual domains of coparenting the amount of conflict between parents regarding childrearing issues and overall household rules the extent to which parents support value and respect each other and triangulation which involves the formation of coalitions between one parent and the child to undermine the involvement of the other parent 6 this model was then expanded specifying joint family management supportundermining childrearing agreement and division of labor as its four main components 2 two years later in response to this model scholars broadened the traditional definition of parenting beyond heterosexual family units and claimed that coparenting encompasses diverse coparent identities and family structures regardless of individuals sexual orientation or relationship status 3 they also argued that flexibility is essential when defining equality in parenting and determining appropriate forms of it as coparents values and beliefs which are often influenced by cultural and environmental factors greatly shape what constitutes coparenting to them a coparent may be absent for a time but still has representational meanings for the other coparent and the child 3 the family system is dynamic with interparental interaction including coparenting support and conflict fluctuating throughout childrens early adolescence 7 compared to western countries research on coparenting in china and neighboring areas began relatively late the first article mentioning the term coparenting was published in 2004 in taiwan focusing on a sample of 309 couples raising preschool children 8 additional studies contributed to an initial wave of coparenting research in mainland china in addition to embracing the shared definition of coparenting that has been derived from mostly western research chinese scholars incorporated chinesespecific elements for the localization of the concept and its research application deepening the research in reference to models suggested by western professionals such as the ecological model of coparenting and supportive and undermining coparenting behaviors within the multilayered family system chinese scholars discussed some phenomena observed in chinese cultures and explained them with cultural factors 5910 for example different from the typically defined collaborative or hostile behaviors in english culture red face and white face is a term used to describe a more blurred coparenting pattern in chinese families in this pattern one coparent adopts a strict and firm parenting style while the other coparent takes on a more nurturing and caring role with the aim of better disciplining and educating their children 11 strict father kind mother is a specific manifestation of this coparenting strategy that is influenced by traditional gender roles 12 assessing coparenting as psychologists have endeavored to expand the boundaries of knowledge in this field the need for standardized scientific measures of coparenting relationships have become substantial several widely used psychometric measurement scales were devised to define the potential components of assessing and evaluating the interparental relationship mchales 16item coparenting scale covers four factors within family relationships family integrity disparagement communication conflict in the childs presence and coparental disciplinary activities out of the four factors family integrity and disciplinary activities are the positive coparenting behaviors and disparagement communication and conflict are the negative ones 13 eleven items involve overt and familylevel behaviors while the other five items focus on covert onetoone activities 14 by capturing expanded coparenting concepts the scale presented a diverse range of family intercourses beyond direct parenting behaviors for the child emphasizing the affection between parents 14 in his later research mchale added coparenting conflict and cohesion as two additional observable variables trained coders observed and coded the videotaped records of assessments of parents and interpreted the data to assess these two variables 15 feinberg and his colleagues also developed scales for coparenting based on a series of exploratory factor analyses and reliability analyses for feinbergs family foundations program the researchers transformed their theoretical conceptualization to three subscales that assess coparental support parentingbased closeness and coparental undermining later as subdomains of support and undermining emerged the researchers created scales to measure coparental agreement exposure of the child to conflict endorsement of partners parenting and division of labor as four other domains 16 17 18 the coparenting relationships scale offers a total score of seven subscales for the overall quality of the coparenting relationship in addition to subscale scores all the domains and the total score exhibit strong internal consistency across parental gender and time points ranging from 061 to 094 18 sometimes certain subscales were extracted and regrouped to measure positive and negative coparenting as well 19 the scale was later translated and revised in other cultures such as italianand portuguesespeaking cultures in china the original seven subscales were shortened to six and the items were also revised 20 the coparenting inventory for parents and adolescents relied on selfreports of parents and children 21 the inventory consists of cooperation conflict and triangulation as three dimensions of coparenting however instead of considering younger children like infants or toddlers adolescents and their parents were the subjects being studied the researchers examined the reliability and validity of the scale the convergence between parents was satisfactory while convergence between parents and their children was weaker yet still statistically significant the analysis supported the salience and necessity of all three dimensions in regard to coparenting some typical types of coparenting patterns assessed with the use of these scales include cooperative families and conflictual families while the former represents connectedness and higher functioning the latter represents more distress and disagreements 2223 some other coparenting patterns though less commonly mentioned in the literature indicated high levels of cooperation and conflicts or disconnected families with low levels of the same 2223 however even though coparenting scales have been developing for many years with various measures created based on different criteria none of these scales are applicable across all family structures and cultures for this study we employed a coparenting scale that we had previously developed which was designed to be more adaptable and flexible this scale was developed by examining relevant literature and combining and condensing items from previous instruments to capture the most important factors outlined in prior scales through the refinement of the emergent themes some common factors were identified across prior research the items included in these factors were factor analyzed in exploratory analysis testing the internal validity of factor structure assembled in different ways until five distinct factors were identified in the coparenting scale used for the current study trust communication animosity valuing the other parent and respect five factors 131 trust as most definitions agree trust consists of peoples expectation that anothers actions will be beneficial favorable or at least not detrimental to them 24 25 26 the way in which people trust others is largely dependent and shaped by their existing experience of being attached to others especially early caregivers secure individuals feel trust due to previous positive trustrelated memories and the ability to set proper relationship goals and strategies in close relationships 27 28 29 30 they also tend to be more willing to commit and build interdependence 3132 a higher level of trust plays the vital role in romantic relationships of reducing negative couple interpersonal outcomes and facilitating positive ones in particular trust serves as a mediator between attachment orientations and relationship outcomes 33 it was found to mediate the relation between female attachment anxietymale attachment avoidance and relationship satisfaction 34 the trust a mother has for her partner mediated her attachment avoidance and coparenting relationship quality 33 a causal relationship was also discovered between destiny beliefs and forgiveness where individuals experiencing the state of attachment anxiety with stronger destiny beliefs are slower to show forgiveness towards their partners 35 with partnerspecific trust mediating the causal relationship the higher level of trust leads to a greater likelihood of forgiveness the research indicated that trust was a significant mediator in explaining an additional 34 of the variability in coparenting conflicts and 35 of the variability in parenting alliances valuing the other parent the degree to which coparents are committed to coparenting is influenced by their mutual feelings towards each other 36 in the process of making plans and taking care of the children coparents may encounter differences in their perspectives and preferences as two coparents witness their childs behaviors they may pursue different approaches to guide the childs development by either actively intervening or going with the flow however the interparental dynamics can be supportive as long as both parents recognize acknowledge and value the potentially distinct qualities inherent in the other parents character or discipline beliefs conversely if one coparent assumes more responsibility for childrearing and possesses more information and authority about the children they may engage in restrictive gatekeeping which refers to the difficulty of relinquishing part of the coparenting responsibilities to the other coparent 36 proper endorsement of another parents parenting involves peoples positive attitudes and behaviors towards their partner regarding childrearing issues 18 this affirmation can be physical or verbal in the presence of the child or not as reflected in everyday life 14 when both coparents value each others role in raising their children it fosters an atmosphere of collaboration and helps to minimize conflict the positive effect of parents working together is particularly evident in stressful situations where reciprocal interparental support and agreement leads parents to work together to solve problems 3738 the active involvement of multiple caregivers helps each caregiver effectively manage daily challenges in childrearing in the context of everyday life maintaining a positive coparenting relationship can benefit the entire family resulting in fewer behavioral problems in children and serving as an indicator of both parents actively contributing to parenting as a unified team 39 respect in order to establish and maintain a successful coparenting relationship it is crucial for partners to collaborate closely and form a strong parenting alliance 240 the idea of the parenting alliance highlights the importance of partners perceptions and feelings about the quality of their coparenting relationship rather than just their interactions even if partners communicate well and make joint decisions their perceptions and attitudes toward each other can still have a significant impact on the success of their coparenting relationship respect is an important but often overlooked aspect of this alliance as it goes beyond just being polite and courteous to the other person and requires actively valuing and being open to the thoughts and behaviors of the other person 41 in romantic relationships where power balance is sought respect is commonly associated with traits such as trustworthiness love care and acceptance and is generally associated with emotional warmth and reciprocity 42 respect is a core value in marital relationships along with commitment intimacy and forgiveness and typically accompanies feelings of admiration and fondness for a partner 4344 although it is not defined similarly across writings and studies empirical studies have demonstrated that respect is closely related to the level of commitment partners have to their relationship their ability to cope with relational trauma their overall satisfaction with the relationship and their willingness to engage in prosocial behaviors 4546 insufficient respect received can be devastating to the maintenance of the coparenting relationship it turned out fathers perception of bad coparenting can lead to their withdrawal from bearing parenting responsibilities and the effect was observed to be less obvious in mothers 47 communication coparents utilize both instrumental and affective communication to exchange information instrumental communication involves discussing basic life issues that require agreement while affective communication involves sharing emotions and feelings by employing these two types of communication consistently parents support each other in response to both negative and positive events that arise in their daily lives to manage challenging situations together partners engage in dyadic coping which entails both partners engaging in a dyadic appraisal of the circumstance and communicating about it with each other 2448 coparents also capitalize on positive events to share happiness and enhance the benefits they experience 49 achieving such synchronization of coparents mental states however requires clear and direct communication clarity ensures the message conveyed is not vague or camouflaged directness requires the message to be directly brought to the other coparent without any intermediaries 50 similar communicative styles also apply to effective parentchild conversations the increased level of conversation orientation is beneficial for children to align the expectations and experiences of parentchild relationships 51 the benefit of effective communication is obvious when one coparent communicates an event it allows the other to respond which can strengthen their bonds and attachments 24 this aligns with the intimacy model proposed in 1988 in which selfdisclosure and response is the foundation to satisfy both parties needs in the interpersonal exchange process since both help to build intimacy in romantic relationships 29 in fact this set of exchanges was named matching support as a request for advice followed by informational support or the disclosure of emotions followed by emotional support 52 providing matching support to the partner who seeks an active response was predictive of higher perceived partner sensitivity and higher marital satisfaction 52 by learning about each other and reducing the gap between perceptions coparents can deepen their understanding and connection which in turn strengthens their relationship on the other side negative communicative patterns within married couples can be devastating to the relationship four types of specific negative behaviors that increase marital conflict and may lead to divorce were listed in the relevant research piececriticism defensiveness contempt and stonewallinglabeled as the four horsemen of the apocalypse 53 criticism involves complaining and attacking the person being criticized defensiveness entails an ineffective selfprotective response in a conversation that can be a counterattack contempt causes psychological harm to the partner through the expression of disgust and disrespect stonewalling occurs when one withdraws from conversation and distances themselves from the partner animosity animosity is a key factor that induces conflicts between parents and dysfunctional interpersonal dynamics it is characterized as a negative global assessment of another partner who is judged to be deserving of no respect as a parent 54 various forms of animosity such as global criticism corrosive contempt shielded defensiveness and passive stonewalling all interfere with normal parenting negotiations and can lead to accumulated stress frustration and emotional distress for both parents in the long term 5054 this massive spiral eventually builds up escalating negative reciprocity within the relationship as the partners guardedness becomes more severe it can result in discouragement towards the other party or even deprivation of opportunities for the other person to spend time with the children this impact is particularly pronounced in men as children 2023 10 1884 6 of 23 their reported depression is largely influenced by coparenting experiences shaped by their female partner 55 animosity can have a spillover effect on the parentchild relationship as the presence of marital animosity experienced by either parent can negatively impact their partners relationship with the child 5657 this can create a conflictridden parenting environment with parents deflecting and redirecting their anger toward their children resulting in less interaction responsiveness and withdrawal from children and an increase in the use of stricter control or punishments 45859 the toxic highconflict interparental dynamics can have a detrimental impact on the functioning of all the other relationships within the family system studying coparenting beyond the western scope while coparenting research has made significant progress in developed western countries there is a significant lack of knowledge about what coparenting and family relationships mean to the other parts of the world particularly china a large number of chinese scholars have focused on grandparentgrandchild intergenerational coparenting instead of parental coparenting in which parents directly bear most of the coparenting responsibility an integrative intergenerational coparenting framework was invented encompassing dimensions beyond the traditional aspects of parenting measurement for example power and authority 60 this trend took place because of the unique structural challenges chinese families have faced over time in rural areas of china many parents opt to work in cities for higher salaries to support their family leaving their children to be cared for by grandparents who reside in their hometowns in cities since the price of housing continues to climb parents usually have to live with grandparents because they themselves cannot afford an apartment 6162 these culturespecific features create a threegeneration family structure in most parts of china which impedes chinese scholars from directly applying western theories about nuclear families to researching chinese families a 2017 national survey found that over 80 of grandparents directly participate in childcare activities for their grandchildren often assuming parental responsibilities 63 due to the prevalence of the phenomenon of raising children across multiple generations most scholars focus on intergenerational parenting in contrast coparenting between parents seems less common as a form of childrearing in china and has not gained sufficient attention from researchers the lack of research on chinese nuclear families has negative implications that extend to the field of social work limited data and results make it challenging for scholars to advocate for policy changes that directly target these families and promote family welfare 64 even as some scholars bring attention to parenting in nuclear families the meaning and implications of parenting styles may differ in china because of culturally specific beliefs derived from taoism and confucianism 65 66 67 chinese parents often base their parenting behaviors on the traditional concept of training children to temper their willpower and cultivate their perseverance which typically involves a higher degree of devotion and strictness 66 parental strictness can be viewed as a display of both concern and caring depending on which of the two forms it manifests parental control or parental organization 6568 as long as the parents parenting behavior fits into the universal framework of the authoritative parenting style it is believed to have a positive impact on the overall development of chinese children resulting in fewer internalizing 69 70 71 72 to understand each cultures coparenting philosophy at a deeper level sociocultural lenses are necessary to provide insight into the environment which shapes patterns of thinking and behaving rather than simply emphasizing research on parentchild interactions or couple relationships which overlook parenting context the inclusion of coparenting helps target interparental relationships and produces meaningful results to inform potential future directions in crosscultural coparenting research until now chinese and english literature have explored coparenting separately with minimal intersection and crosscultural comparison despite the fact that scholars have accumulated rich knowledge about coparenting within their respective countries or areas this study aims to bridge the gap between these two cultures and stimulate conversation on coparenting ideologies that are shared or divergent among parents from the other side of the world through preliminary exploration this study aims to establish a significant foundation for guiding future crosscultural research efforts in this area this research will not only inform the analytical strategies needed for comparing chinese and english cultures but also for any other two cultures the present study and the research questions in the present study we examine the validity of the coparenting measurement tool copafs which contains five factors to test the feasibility of applying it in a chinese context furthermore we utilize this tool to compare differences in coparenting ideologies across english and chinese cultures with a specific focus on married couples the data analysis quantitatively accounts for differences in the strength of associations between englishspeaking and chinese parents and furthermore explores the key determinants causing such differences materials and methods this study consists of four questions 1 does the measurement model underlying the copafs scale exhibit a good fit with the data gathered from chinese parents 2 what are the differences in the relative importance of each factor in terms of each of the factor loadings on coparenting as the latent construct compared between the englishspeaking parents and the chinese parents 3 does gender significantly account for the variation on coparenting as well each of the five factors measured by the copafs scale 4 does culture significantly account for the variation on coparenting as well each of the five factors measured by the copafs scale in respect to each of these research questions we offer the following hypotheses h1 the copafs measurement model exhibits a good model fit on the data collected from married chinese parents h2 the relative importance of the factors in terms of factor loadings on coparenting as the latent construct varies significantly between the englishspeaking parents and the chinese parents h3 gender significantly accounts for the variation on the copafs scale as a whole and on each of the five factors both for englishspeaking parents and for chinese parents h4 culture significantly accounts for the variation on the copafs scale as a whole and on each of the five factors both for englishspeaking parents and for chinese parents instruments coparenting was measured using the short form 27item version of coparenting across family structures scale which was developed by michael saini and marsha kline pruitt and validated in their followup study published in 2019 73 figure 1 shows the structure of the model children 2023 10 1884 10 of 23 instruments coparenting was measured using the short form 27item version of coparenting across family structures scale which was developed by michael saini and marsha kline pruitt and validated in their followup study published in 2019 73 figure 1 shows the structure of the model the scale comprises 5 subscales animosity value trust respect and communication and is intended to measure coparenting dynamics across all family structures the 27 items are each categorized into one of the five subscales and were measured by a 5point likert scale ranging from 1 strongly disagree to 5 strongly agree all items were originally developed in english then they were translated by one mandarin native speaker and were reviewed and finetuned by a mandarinspeaking research assistant and a sociology professor at a leading chinese university with expertise in the field of coparenting the triple check process ensured the accuracy of the statements and their cultural adaptations due to linguistic subtleties when arranging all the items on the survey the order was randomly shuffled so items would not cluster together around each factor in the original survey some questions are positively phrased while some are negatively phrased a strong agreement with a high score on some questions may refer to a low level of the attribute being measured while other questions are measured in the reverse way to have all the directions of the questions consistent for later addition of the total scores the scores on questions 3 5 7 8 10 11 13 15 17 18 20 22 24 25 and 27 were reversed table 4 shows the full list of questions below 1 it is important that my child loves both parents v 2 i value the other parents parenting skills r 3 i feel awkward when i am with the other parent a 4 i work well with the other parent when decisions need to be made about our child c 5 i am hostile or biting in my conversations with the other parent a the scale comprises 5 subscales animosity value trust respect and communication and is intended to measure coparenting dynamics across all family structures the 27 items are each categorized into one of the five subscales and were measured by a 5point likert scale ranging from 1 strongly disagree to 5 strongly agree all items were originally developed in english then they were translated by one mandarin native speaker and were reviewed and finetuned by a mandarinspeaking research assistant and a sociology professor at a leading chinese university with expertise in the field of coparenting the triple check process ensured the accuracy of the statements and their cultural adaptations due to linguistic subtleties when arranging all the items on the survey the order was randomly shuffled so items would not cluster together around each factor in the original survey some questions are positively phrased while some are negatively phrased a strong agreement with a high score on some questions may refer to a low level of the attribute being measured while other questions are measured in the reverse way to have all the directions of the questions consistent for later addition of the total scores the scores on questions 3 5 7 8 10 11 13 15 17 18 20 22 24 25 and 27 were reversed table 4 shows the full list of questions below the other parent tries to be a good parent but does not know enough about parenting to be the kind of parent our child needs t in the right column each letter corresponds to a factor name t trust v valuing the other parent r respect c communication a animosity the asterisk sign represents the items being reversed data collection procedure the survey was circulated among parents in china and in north america englishspeaking parents were recruited through multiple online platforms such as facebook instagram parenting organizations and some personal networks of our colleagues in the case of chinese parents in addition to these listed resources we also sent out flyers to wechat groups and wechat public official accounts our chinese colleague also referred us to some local nonprofit organizations she collaborated with as well an online version of the survey was offered to the participants which took them around 30 min to complete once they gave the informed consent at the beginning of the survey the participants were informed about their rights to inquire about the research or express any concerns as well as the potential risks and how to contact the researchers andor smith college irb the whole process protected participants anonymity and their datas confidentiality personal information was neither requested nor collected and responses were not shared with any external sources in full observance of the protocol approved by the smith college irb data analysis strategies we utilized 11 v29 and its extension spss amos v28 to complete all the necessary statistical analysis to test the stability of the shortform copafs factor structure the chinese sample was divided into 2 subsamples chinese mothers chinese fathers for each group the psychometric properties of the shortform scale and the 5 subscales around which the 27 items were hypothesized to cluster were calculated to test the validity of the shortform 27item copafs in its mandarin translation as it was found to perform well in englishspeaking samples in the previous study the internal consistency of each of the 5 subscales and the shortform copafs scale as a whole was expressed in terms of the cronbachs alpha coefficients confirmatory factor analyses were conducted with a maximum likelihood estimation method for each of the 5 subscales on both chinese mothers and fathers which assessed how well the measurement model captured the covariance between the items composing the 5 factors in terms of the whole scale the analyses showed how well the measurement model captured the covariance between the 5 subscales multiple model fit indices were calculated and reported first a chisquared test indicating the difference between observed and expected covariance metrics was calculated however as the value is strongly influenced by the sample size this could be misleading in either small samples or large samples a sample size above 200 cases may result in nonsignificance even when the model is appropriate 74 second the root mean square residual showing the square root of the discrepancy between the sample covariance matrix and the model covariance matrix was calculated third the comparative fit index representing the discrepancy between the data and the hypothesized model was calculated while adjusting for issues of sample size inherent in the chisquared test of model fit fourth the root mean square error of approximation measuring the discrepancy between the hypothesized model with optimally chosen parameter estimates and the variance matrix was calculated and reported the analysis also estimated the regression coefficients for each factor and the proportion of the variation explained by the factors relative to the whole model providing information about the stability of the construct across groupsthe extent to which the subscales and the whole scale measure what they were intended to measure thus it helped determine the comparability and accuracy of the model when applied to different groups last a set of multigroup invariance analyses were conducted to determine whether gender or cultureor bothwere significantly related to variation on the coparenting scale as a whole and on each of the five factors with the data collected from each group invariance analysis helped test the stability of the factor structure of the copafs scale and the individual parameters for equivalence across groups with conditions being gradually constrained configural metric and scalar invariance were tested configural invariance revealed if the same general specification of the model holds across the groups of participants and exhibits a good fit across groups while allowing the parameters of the unconstrained model within each group to be freely estimated metric invariance added further equality constraints to structural covariances scalar invariance constrains the measurement residuals in addition to the previous conditions results model fit examination of copafs scale using the data collected from chinese parents cronbach alpha values and the correlation matrices for five factors given that the internal validity of the copafs model for englishspeaking families was already examined and demonstrated in a previous study the first part of the results will solely report the cronbach alpha coefficients and model fit indices for chinese families 73 the cronbach alpha coefficient which estimates the extent to which the items in the scale are measuring the same underlying concept yielded a value of 0925 for the entire copafs scale in married chinese families on a scale from 0 to 1 such a high value indicates an excellent level of internal consistency of this scale to measure the coparenting relationship of chinese families as a closely related set of items however the cronbach alpha coefficients for each factor vary considerably ranging from quite satisfactory high values to low ones indicating poor internal consistency as indicated in table 5 below trust animosity and communication exhibited high cronbach alpha coefficient values implying the participants response values across the subsets of questions were very consistent however valuing the other parent and respect showed low values implying loose interrelations across items within these two subscales beyond the investigation of internal consistency of the single subscales correlations between the factors were also calculated to explore overlaps between the different subscales table 6 indicates moderate to high positive correlations between most factors suggesting that the subscales may measure similar concepts it is important to note however that these findings may also be attributed to the closely clustered nature of familyrelated concepts in peoples minds which might make it difficult for individuals to clearly differentiate between these five dimensions model fit indices for chinese mothers the chisquared value of the whole model was 352981 which is high for the differences between observed and expected covariance metrics however the value of x 2 m is overly sensitive to the sample size when testing the effectiveness of a model across different populations 7576 therefore there is no specific range of chisquared values that can be considered universally good or bad the root mean square residual was 0887 the square root of the difference between sample and model covariance matrix a value less than 008 is generally acknowledged as indicative of a good model fit after adjusting for the sample size representing the chisquared value the comparative fit index was calculated to be 0762 which is lower than the common acceptable cutoff value of 09 this value demonstrates the degree of discrepancy between the data and the model that was hypothesized the root mean square error of approximation value was 0399 which manifests the difference between the hypothesized model using the best parameter estimates and the variance matrix however this value is greater than 008 as the acceptable cutoff value for chinese fathers the value of the chisquared test was 101288 the rmr value was 104 the cfi value was 0718 the rmsea value was 0448 these model indices served as continuous indicators of the modeldata correspondence and could be interpreted as goodness or badness of fit of the model though some indices are quite sensitive to sample size others are not after combining the indices obtained from both chinese mothers and fathers and evaluating them we found that both patterns were similarly suboptimal the copafs model as a whole did not appear to be a particularly strong fit for the data indicating that it may require further refinement in future studies in order to improve its ability to accurately replicate the english data for chinese married families generally the statistics refute the first hypothesis this information is valuable for future research as efforts are needed to improve and refine the model until adequate model fit can be demonstrated yet additional information gleaned from the analyses suggests a more complicated picture than a simple rejection the relative importance of each factor as endorsed by englishspeaking parents and chinese parents factor loading analyses we next explored the strength of the relationships between each factor and the latent variable the coparenting relationship across all sample groups a higher value indicates a stronger association of the factor in accounting for the proportion of variance on the latent construct the maximum value for both the regression coefficient and variance of the coparenting relationship itself was set to 1 the regression coefficients of each subscale for chinese mothers ranged from 098 to 000 with animosity having the highest coefficient of 098 trust as 086 valuing the other parent as 075 respect as 057 and communication with 000 as the lowest all the results are statistically significant except for communication the results showed that chinese mothers are most attentive to animosity and least attentive to communication while evaluating the coparenting relationship the proportions of the variation of each subscale accounted for on the underlying construct were calculated along with the regression coefficients animosity explained 967 of the variance trust explained 744 valuing the other parent explained 572 respect explained 327 and communication explained 00 the pattern for chinese fathers was nearly identical to that of mothers the highest regression coefficient was 097 for animosity then 090 for trust 072 for valuing the other parent 052 for respect and 003 for communication animosity explained 945 of the variance trust explained 821 valuing the other parent explained 531 respect explained 271 and communication explained 00 again all the results were statistically significant except for communication according to these regression coefficients the communication factor did not explain any of the variation in the coparenting relationship quality for both chinese mothers and chinese fathers among chinese parents the understanding of a good coparenting relationship specified by the five subscales was quite different than in western culture trust and respect had the same highest correlation coefficients of 089 among englishspeaking mothers then the correlation was 087 for animosity 086 for communication and 071 for valuing the other parent trust and respect both explained 803 of the variance animosity explained 772 communication explained 747 and valuing the other parent explained 506 all the results are statistically significant a similar hierarchy of the importance of the subscales was found in englishspeaking fathers trust has the highest coefficient of 097 respect is 087 communication is 083 animosity is 082 and valuing the other parent is 081 all the results are statistically significant trust explained 870 of the variance respect explained 769 animosity explained 762 communication explained 704 and valuing the other parent explained 665 all five subscales were important to englishspeaking parents commenting on their coparenting relationships the major contrast between englishspeaking parents and chinese parents attitudes was the importance ascribed to respect and communication chinese parents tended to place less emphasis on respect as a factor contributing to a healthy coparenting relationship while communication was even deemed to be almost irrelevant in chinese culture in contrast both respect and communication were significantly more influential in the opinions of englishspeaking parents and received the same credit as the three other factors given all of the statistics above the second hypothesis was accepted because there were structural differences in the strength of correlations between englishspeaking and chinese couples testing the significance of gender and culture as two predictors that account for the variation in coparenting and the five factors multigroup invariance analysis as slight differences in gender and the disparate gap in regressions between respect and communication and coparenting relationship were observed between the two cultures in the second research question the importance of gender and culture as factors that explain noteworthy differences was investigated controlling for either gender or culture four multigroup invariance tests of the model were run each testing for configural metric and scalar invariances in the general measurement model three covariances between value and communication respect and communication and value and respect were present and acknowledged for more accurate outcomes the invariance was tested between chinese mothers and fathers englishspeaking mothers and fathers chinese mothers and englishspeaking mothers and chinese fathers and englishspeaking fathers results are summarized below in tables 811 table 8 compared chinese mothers and fathers to see if gender would be a predictor of significant differences in chinese culture at the configural level cfi is 099 and rmsea is 005 which showed the great fit of the model in terms of configural arrangement across chinese mothers and fathers at the metric level which constrained structural covariance the chisquared value is not significant and the null hypothesis that there was equivalence in factor variances and covariances between the two groups was accepted moving to the most restrictive scalar level the chisquared value was still nonsignificant the fit of the model was ensured with the invariance of measurement residuals at all three levels of invariance analysis there was no significant variance between chinese mothers and fathers thus it was concluded that gender was not a significant predictor of the variation on the coparenting scale as a whole nor on each of the five subscales for chinese parents table 9 compared englishspeaking mothers and fathers at the configural level cfi is 093 which is good while rmsea is 014 which is weak the statistics showed the model is acceptable in terms of configural arrangement across englishspeaking mothers and fathers at the metric level the chisquared value is not significant and the null hypothesis was accepted indicating that there was equivalence in factor variances and covariances between the two groups moving to the most restrictive scalar level the chisquared value was still nonsignificant the fit of the model was ensured with the invariance of measurement residuals at all three levels we found only significant invariance between englishspeaking mothers and fathers thus similarly to chinese parents it was concluded that gender was not a significant predictor of the variation on the coparenting scale as a whole nor on each of the five subscales in englishspeaking parents overall neither chinese nor englishspeaking parents illustrated distinct differences explained by their gender in response to the third research question gender was not found to be a significant predictor of the variation on coparenting the hypothesis to the third research question was hence rejected next two multigroup invariance tests were conducted to assess culture as a potential predictor while holding gender constant for both tests the cfi and rmsea values were not ideal cfi did not reach the benchmark of excellence while rmsea was higher than the normally accepted value suggesting the model fit was inadequate consequently null hypotheses at both metric and scalar level were rejected claiming that the structure of the model significantly differed between chinese and englishspeaking mothers it became apparent that culture was a significant predictor of variation in the coparenting scale and its five subscales for mothers across both cultures in the process of accumulating profiles for the coparenting relationship culture carried more weight than gender comparing tables 10 and11 the results of the comparison of the two father groups differed in comparison to the mother groups the metric invariance was accepted but not the scalar invariance taking measurement weights and structural covariance into account supported that there is no significant variance of the model between chinese and englishspeaking fathers however once restraining the measurement residuals significant differences appeared which is the same as mothers scalarlevel invariance comparison strictly speaking the result still showed a significant cultural effect on fathers values towards the five factors using the strictest level of multigroup invariance analysis results indicated that culture was a statistically significant factor associated with differences in coparenting across groups the findings suggest that the weight of each factor that influences coparenting relationships may differ significantly depending on the cultural context in which one responds to the items thus the fourth hypothesis that highlights the importance of culture was accepted discussion research overview built upon the review of the theoretical framework and measures constructed by other scholars in the coparenting field the copafs scale was developed to expand research on families in different contexts such as diverse family structures or cultures 141618 in the past few years englishspeaking parents with different marital statuses were used to validate the copafs scale in north america but the crosscultural feature of the scale as part of the original goal has not been explored and examined until now 73 in this study the overarching objective is to identify similarities or differences between englishspeaking and chinese married parents in recognition of the factors constituting coparenting relationship wellbeing via this innovative measurement tool we first estimated the fit of the copafs model in the chinese context then we measured the strength of different factors in both cultures with noticeable significant differences across groups we further investigated whether gender or culture contributed to such variations model fit of copafs under the chinese context although the copafs model was proven to be a valid measurement for englishspeaking participants the application of the model did not demonstrate effectiveness in this pilot study in a chinese context 73 we first investigated how well the items are closely clustered within the whole scale and each subscale the cronbach alpha value for the entire scale is 0925 which represents quite a high internal consistency of the scale however values of certain factors specifically valuing the other parents and respect are low compared to information obtained from englishspeaking parents showing that items within these two factors are more loosely interrelated as we further looked into various model fit indices generated from chinese participants the general conclusion we reached is that the overall model was a suboptimal fit for the chinese parents the unsatisfactory results we obtained suggest that the current copafs model is not yet an adequate representative measurement tool for the data from the recruited chinese married parents and should not be immediately applied for probing chinese parenting in real life the differences do not stem only from language differences but from cultural differences as the chinese sample emanated from china they were not chinesespeaking americans the model requires further refinement and localization before the researchers can use this tool to interpret the responses from chinese parents accurately to achieve this goal a more theoretical understanding of the chinese coparenting relationship is required for improving the scale a larger sample already under way may better account for cultural nuances in coparenting among the chinese parents different views of chinese and englishspeaking parents on elements of parenting moving from model examination to additional results we used confirmatory factor analyses to test relationship strengths between each of the factors and the holistic coparenting relationship the results illustrated statistically significant differences between chinese and englishspeaking parents in the weight they gave to communication and respect when evaluating the quality of their coparenting relationship with the regression coefficients being 000 and 003 for chinese mothers and fathers chinese parents showed a striking indifference towards the level of communication in coparenting much higher weight was given by englishspeaking parents with both regression coefficients hovering at approximately 85 the limited appreciation for communication in chinese coparenting seems contradictory to most western literature that emphasizes the significance of communication in facilitating positive coparental conversation and coparents individual wellbeing 2452 a potential explanation pertains to gendertyped caregiving patterns that exist more or less in chinese families 77 there has traditionally been a greater emphasis on the parental role compared to the spousal role 78 other research supports that women tend to compartmentalize the distinct roles of being a parent versus being a spouse 79 in most areas or countries fathers traditionally are involved less in childcare than mothers 80 while the proportion of fathers actively participating in childcare activities has increased in western industrialized countries chinese fathers in general maintain their secondary provider role which offers more financial than parenting support to meet the rigid social expectation of gender roles 8182 in contrast chinese mothers spend more time with children as emotional supporters and provide more practical care 82 some chinese mothers express satisfaction with their role as caregiver and do not actively seek practical assistance from the childs father in infant care 83 this division of parenting responsibility forms an interesting phenomenon summarized by an old chinese saying men work outside and women take care of the home which has gained renewed attention in china recently 8485 the tacit assumption of gender roles in chinese culture may be a contributing factor to the lower perceived need for communication among chinese parents due to the implicit division of parenting responsibilities based on gender there may be less overlap in childrearing tasks for chinese parents to discuss and reconcile as a result chinese parents are more likely to rely on their own perceptions of responsibilities and complementary roles of the other parent when participating in the childrearing process 82 in addition to communication respect was also found to be of relatively less importance in the coparenting environment of chinese parents while the regression coefficients of respect are 057 and 052 for chinese mothers and fathers the same coefficients are 089 and 087 for englishspeaking mothers and fathers in comparison chinese parents valued respect nearly 30 less than englishspeaking parents the obvious difference in the respect domain between chinese and englishspeaking parents might be ascribed to the shared sociocultural environment that most chinese participants experienced the majority of them included in this study were urban residents born during the nationwide implementation of chinas onechild policy the policy restricted the number of children married urban couples could have to one in order to control chinas population growth there is a dramatic shift in personalities in the younger generation from their parents 86 as the only child in the family they were invested with more resources and tended to exhibit stronger individualistic characteristics and more openmindedness towards entering marriage or not even if they are married they are less tolerant of their partners different opinions 87 these rigid views of parenting roles may lead to less effort or adherence to parental collaboration regarding decisions and practices of the other parent which in turn may contribute to their lower recognition of the importance of respect culture as the more dominant predictor than gender multigroup invariance analyses were used to explore whether gender or culture accounted for differences in weights of coparenting factors across four groups it was discovered that rather than gender culture was related to more significant variation in the copafs subscales at the most restrictive scalar level of the analyses significant variances were found between chinese mothers and englishspeaking mothers as well as chinese fathers and englishspeaking fathers culture is a social construct that is fulfilled with sets of distinct beliefs and behaviors that are shared by people living in the same culture to regulate their behaviors 88 coparenting ideologies are learned behaviors that differ according to what is deemed normative in a particular culture even though the common goal shared by all parents across the world is to nurture and encourage their children to be competent in their society the ways to achieve that goal vary greatly across cultural groups 8990 for example there are significant variations in maternal behaviors across modern industrialized countries such as argentina belgium israel italy and the us 88 additionally levels of progressive parenting attitudes and modernity of childrearing attitudes vary considerably across countries as diverse as china colombia italy jordan kenya the philippines sweden thailand and the us 88 previous research has also compared attachment and selfregulation patterns of us and japanese mothers 8891 however current literature on chinese parenting mostly focuses on chinese immigrant families in the us rather than chinese residents born in china thus there is a lack of direct comparison between englishspeaking and chinese local cultures this study provides a crucial piece of the puzzle for integrating crosscultural parenting comparisons with empirical evidence that highlights the differences between these two cultures furthermore this study serves as a resource for parenting scholars researching crosscultural parenting styles both conceptually and methodologically limitations and future research as mentioned earlier it is crucial to ensure the copafs scales model fits the chinese culture to interpret the data accurately to achieve crosscultural validity of instruments additional efforts are necessary to establish adapted equivalence 92 qualitative studies may be required to understand cultural and interpersonal dynamics among chinese parents to enhance the instruments accuracy it is also essential to confirm the conceptualization of profiles grouped under different factors to ensure that the measurement subscales have the same meaning across different cultural groups or it may be fruitful to encourage analysis of different meanings ascribed across cultures to the concept of coparenting regarding the methodology of this study a set of multigroup invariance tests were used to calculate the pvalues determining whether there were statistically significant differences by gender or culture given the sample size of nearly 1000 participants statistically significant results could also be due to the large sample size 60 though the copafs model shows some large differences in communication and respect between two cultures coparenting the survey was completed by only 534 chinese parents as the first wave of participants outside an englishspeaking culture there are likely geographical sampling limitations to this first study report moreover the composition of participants recruited in this study are mostly middleclass and welleducated people with a relatively low father participation rate compared to mothers as a result research findings may have low generalizability to populations characterized by different demographics for future research there are a few directions that can be extended in further investigation first although this study showed a poor model fit of the copafs scale for married chinese parents the model fit indices should be reexamined in other chinese family structures including those with mothergrandparent coparenting pairs second this study did not account for the variance within english datasets such as the racial and ethnic distribution of participants as it focused on a broader culturelevel comparison however future copafs studies that focus on englishspeaking populations might investigate racial diversity as an essential theme within and across englishspeaking participants from differing cultural backgrounds conclusions this study tested the validity of the copafs model and used it as a tool to reveal crosscultural differences in coparenting constructs between chinese and englishspeaking married families a series of model fit calculations revealed the currently limited applicability of the copafs model in explaining chinese parents responses this finding challenged our initial hypothesis and highlights the need for future work to revise and enhance the crosscultural adaptability of the scale in light of this realization this study ventured to compare parents from two distinct cultures revealing a sharp contrast between the two in terms of the endorsement of respect and communication the result substantiated our second hypothesis which posits that the relative importance of the factors varies significantly between parents from two cultures in order to examine the potential contributions of gender and culture multigroup invariance analyses were conducted to test our third and fourth hypotheses these analyses yielded novel evidence indicating that culture has a significant influence on the coparenting constructs endorsed by both chinese and englishspeaking parents while the influence of gender was found to be less pronounced as a result the gender hypothesis was rejected while the culture hypothesis was accepted overall the findings of this study underscore the critical role of cultural context in the study of coparenting relationships and identifies promising new research directions for future studies employing the copafs model there are a few practical as well as empirical implications in relation to this study although we have raised a popular genderrelated childrearing pattern in china as one possible reason why communication receives almost no attention from chinese parents there is currently little chinese literature directly addressing communication within the couples relationship using this genderdetermined parenting theory to explain this children 2023 10 1884 20 of 23 cultural difference would be challenging without first confirming the connection between presumed work division and the low endorsement of communication therefore further investigation is recommended in this area to delve deeper into this connection the same mechanism applies to the concept of respect the onechild policy should only be considered to be just one of many social factors that contribute to the diminished significance of respect between parents it may not be the most influential factor or there could potentially be a mediating variable that directly impacts parents values therefore conducting further research is necessary before a definitive and confident conclusion can be reached regarding the factors contributing to the downplaying of respect by chinese parents finally the high endorsement of hostility among the participants raises interesting questions about the nature of marriages in china and the role of conflict or anger in downplaying communication and respect perhaps the lack of communication helps keep the lid on covert hostilities that are intrapersonal and perhaps structurally created by conditions in chinese society such questions await further research with important implications for the wellbeing of chinas children and families data availability statement data are available to all interested parties upon reasonable request author contributions conceptualization tz and mkp methodology ja tz and mkp software tz validation ja and tz formal analysis ja and tz investigation mkp tz and ja data curation tz writingoriginal draft preparation tz and mkp writingreview and editing mkp and ja supervision mkp project administration mkp funding acquisition mkp all authors have read and agreed to the published version of the manuscript informed consent statement written informed consent was obtained from all subjects involved in this study to publish this paper

while coparentingrelated conceptual frameworks and empirical studies have received considerable attention in western countries there is far less attention on this topic in other regions this study seeks to fill this gap by comparing coparenting dynamics between englishspeaking and chinese parents this study begins by reviewing coparenting relationships in both western and chinese contexts study participants comprised 399 englishspeaking parents living in the us and canada and 534 chinese parents living in mainland china there were several waves of participant recruitment by sending out the flyers online or utilizing the professional networks to invite eligible parents the measurement tool copafs coparenting across family structures which has been validated in englishspeaking culture was used to compare the differences in coparenting constructs in two cultures first the model fit of copafs within chinese culture was examined with cronbach alpha values and relevant model fit indices such as comparative fit index and root mean square residual as most of the statistics fell below the expected level of excellence there is a need to locally adjust the entire model in order to better interpret chinese parenting the intensity of connection between each factor included in the model and the coparenting relationship as a whole was then investigated although most factors were endorsed similarly by chinese and englishspeaking parents there were notable differences in their opinions regarding communication and trust while englishspeaking parents highly valued these two elements within the coparenting process chinese parents showed almost no attentiveness to them in order to understand factors that may contribute to such a sharp contrast two main variables culture and gender were tested through a series of multigroup invariance analyses assessing equivalence across groups it was discovered that culture emerged as the more dominant determinant among the groups of participants the implications of crosscultural use of the copafs tool and future research directions are discussed

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introduction approximately 13 billion individuals or 16 of the global population live with some form of disability the increasing prevalences of disabilities coupled with factors such as an aging population advancements in medical technology evolving definitions of disability environmental degradation and unhealthy lifestyles have garnered significant scholarly attention previous studies have explored the spatial distribution in pods that varies significantly across the globe continents countries provinces and cities 12 moreover the prevalence of specific disability types and the factors influencing their spatial distribution exhibit substantial variation 3 however given the significant disparities in ruralurban development there is currently limited research on the pods within cities furthermore there is a lack of indepth analysis on the incidence of different types of disabilities and their associated factors therefore there is a pressing need for more comprehensive studies to enhance our understanding of disability prevalence and its multifaceted aspects within urban settings urbanrural disparities of pods evaluations of spatial disparities in pods at different scales have yielded inconsistent results globally pods are lower in the global north and higher in the global south due to factors such as limited healthcare access poverty malnutrition insufficient education and employment opportunities and unsafe living conditions 4 urbanrural disparities in pods are prevalent in the global south velayutham et al demonstrated that disability rates in india were higher in rural areas compared to urban ones 5 zheng et al found that between 1987 and2006 in china pods in rural areas were consistently higher than in urban areas exhibiting a notable upward trend 6 a study in monaco also revealed that factors such as older age lower education levels unemployment being single and living in rural areas were associated with higher prevalence rates of disability which varied widely geographically 7 different types of pods also vary between urban and rural settings in the united states for instance adults living in rural counties were 9 more likely to report having a disability in 2016 24 more likely to report having three or more disabilities and 7 to 35 more likely to report cognition and hearing disabilities than those living in large metropolitan centers 8 hajjioui et al found that individuals living in rural areas in morocco were associated with higher pods with visual and motor impairments being the most common disability modalities 7 research on limb disability shows conflicting findings urban areas may exhibit diverse limb disabilities from aging accidents violence and congenital conditions 9 while rural areas may have higher rates due to agricultural accidents lack of safety regulations and limited access to rehabilitation services 10 research findings on the prevalence of intellectual disabilities in urban and rural areas are inconclusive as various factors such as genetic conditions prenatal care and environmental factors contribute to the complexity of the relationship 1112 furthermore urban areas may have higher rates of mental health disorders and emotional disabilities due to various stressors lifestyle factors and the availability of mental health services 13 associated factors contributing to urbanrural disparities of pods differences in pods between urban and rural areas primarily stem from variations in socioeconomic and built environments 56 on one hand research on disability which originated in the medical field emphasized the medicalization of disability as a significant factor in societys marginal treatment of disability issues consequently disabilityrelated medical and public health services play a crucial role in the rehabilitation and treatment of disabled individuals as well as in the urbanrural disability prevalence gap 14 a 1997 study found that communicable maternal perinatal and nutritional disorders accounted for 439 of the causes of death and disability worldwide 15 these disorders disproportionately burden rural areas particularly in the global south 16 the world health organization noted that the rising pods were attributable to aging populations higher risks of disability among older individuals and the global increase in chronic health conditions such as diabetes cardiovascular disease cancer and mental health disorders numerous studies confirmed that a wider prevalence gap between rural and urban areas is observed among older groups particularly concerning hearing visual and limb disabilities 17 due to persistent inefficiencies and uneven resource distribution as well as differences in economics healthcare urbanization and population density between urban and rural areas it is challenging to foresee significant improvements in care services and elderly care in rural areas anytime soon 9 urbanization and industrialization reflected in the development of transport systems such as station density and road network density introduce environmental factors that may contribute to disability incidence for example higher pollution levels or exposure to toxins in densely populated areas could potentially impact respiratory health leading to respiratory disabilities 18 similarly increased traffic density might raise the risk of accidents resulting in various types of disabilities 19 on the other hand the social model reconceptualized the medical model positing that social attitudinal and environmental barriers in society play a significant role in disabling individuals with physical andor mental impairments 20 this perspective raised academic concerns about whether rural and urban contexts are more or less likely to facilitate participation and social inclusion for those with or without disabilities it also determines the role of social participation in shaping subjective feelings of social integration people living in rural areas are more likely to be less educated unemployed single and alienated from friends and relatives factors associated with higher disability prevalence rates 9 individuals working in rural areas or rural migrants often encounter challenging work environments and perceptions of compensability which significantly contribute to the incidence of chronic disability moreover they may encounter barriers in accessing social activities community events or maintaining social connections leading to social isolation and negative impacts on mental health such as higher rates of depression anxiety and reduced overall wellbeing 21 research gaps to summarize most empirical studies predominantly support disparities in disability prevalence attributed to unequal development and urbanrural heterogeneity across various disability types however these studies have been limited to an urbanrural binary perspective and seldom visualize spatial differences in disability prevalence based on urban spatial structure furthermore explaining the spatial distribution of different types of disability within urban spaces has proven challenging secondly although studies have investigated the influence of socioeconomic factors and built environments on disparities in disability prevalence between urban and rural areas there is a limited exploration of the heterogeneity of these effects across different disability types furthermore the diverse spatial patterns of disability prevalence especially in less developed countries and regions have received insufficient attention as a developing country with the worlds largest disabled population china has always prioritized disability issues in the world health organizations agenda this study choses tianjin a representative large city in china as the research area it divides tianjin into urban centers urban fringes and rural areas to examine the spatial patterns of pods and urbanrural disparities in the prevalence of different disability types within the municipality using aggregated registration information from the tianjin disability database 2020 it also analyzes the impacts of related socioeconomic factors and built environments on the spatial prevalence of different disability types extracting various dominant elements specifically two key research questions will be answered whether significant urbanrural disparities exist in the spatial distribution of pods and which disability types are concentrated in urban areas urban fringes or rural areas what are the associated factors influencing pods and which factors dominate for different disability types methods study area tianjin a significant industrial megacity southeast of beijing was chosen as the study area according to the tianjin master plan tianjins subdistricts can be classified into three regions urban center urban fringe and rural areas in 2020 the number of certified disabled individuals reached approximately 350000 representing a diverse crosssection of ages genders and types of disabilities there are seven types of disabilities including up to 235200 persons with limb disabilities fewer than 10000 individuals with speech and multiple disabilities and between 20000 and 30000 persons with intellectual mental hearing and visual disabilities number of certified disabled individuals reached approximately 350000 representing a diverse crosssection of ages genders and types of disabilities there are seven types of disabilities including up to 235200 persons with limb disabilities fewer than 10000 individuals with speech and multiple disabilities and between 20000 and 30000 persons with intellectual mental hearing and visual disabilities data collection this study utilized four primary data sources firstly we collated the spatial location data of different types of certified disabled people at the subdistrict level from the tianjin disability database secondly we collected information on the location and descriptors of disability service facilities such as disability schools disabilities daycare centers rehabilitation centers integrated disabled services and disability employment services including their type year of construction area medical and nursing personnel numbers from the database of disabled facilities in tianjin both types of data sources used in this study were obtained through a cooperation project with the tianjin disabled persons federation the project aimed to assess the adequacy of public service facility planning for individuals with disabilities primarily based on the distribution of the disabled population the details of the data processing have been described elsewhere 22 thirdly we obtained location data on public service facilities from gaode map poi data fourthly we acquired population data at the subdistrict level from number of certified disabled individuals reached approximately 350000 representing a diverse crosssection of ages genders and types of disabilities there are seven types of disabilities including up to 235200 persons with limb disabilities fewer than 10000 individuals with speech and multiple disabilities and between 20000 and 30000 persons with intellectual mental hearing and visual disabilities data collection this study utilized four primary data sources firstly we collated the spatial location data of different types of certified disabled people at the subdistrict level from the tianjin disability database secondly we collected information on the location and descriptors of disability service facilities such as disability schools disabilities daycare centers rehabilitation centers integrated disabled services and disability employment services including their type year of construction area medical and nursing personnel numbers from the database of disabled facilities in tianjin both types of data sources used in this study were obtained through a cooperation project with the tianjin disabled persons federation the project aimed to assess the adequacy of public service facility planning for individuals with disabilities primarily based on the distribution of the disabled population the details of the data processing have been described elsewhere 22 thirdly we obtained location data on public service facilities from gaode map poi data fourthly we acquired population data at the subdistrict level from data collection this study utilized four primary data sources firstly we collated the spatial location data of different types of certified disabled people at the subdistrict level from the tianjin disability database secondly we collected information on the location and descriptors of disability service facilities such as disability schools disabilities daycare centers rehabilitation centers integrated disabled services and disability employment services including their type year of construction area medical and nursing personnel numbers from the database of disabled facilities in tianjin both types of data sources used in this study were obtained through a cooperation project with the tianjin disabled persons federation the project aimed to assess the adequacy of public service facility planning for individuals with disabilities primarily based on the distribution of the disabled population the details of the data processing have been described elsewhere 22 thirdly we obtained location data on public service facilities from gaode map poi data fourthly we acquired population data at the subdistrict level from the seventh census in 2020 economic and urbanization data were drawn from the tianjin districtlevel statistical yearbook for 2021 hotspot analysis of pods we initially performed a normality test on both the total pods and different types of pods the results revealed that neither the total pods nor individual types of pods followed a normal distribution this nonnormal distribution made them suitable for the application of the getisord gi statistics subsequently we then utilized the getisord statistic to identify pod hotspots this test assesses whether the clusters of crashes are statistically significant the resultant z value expressed either high or low values of neighboring features features with a high value may not be a statistically significant hot spot to be a statistically significant hotspot a feature will have a high value and be surrounded by other features with high values as well a positive z score indicates a hotspot and the larger the z scores the more intense the clustering while a z score indicates cold spot and the smaller the z score indicates the more intense clustering of low values 23 the getisord general g and getisord local statistics are given as equations and g ∑ n i1 ∑ n j1 w ij x i x j ∑ n i1 ∑ n j1 x i x j g i ∑ n j1 w ij x i ∑ n j1 x i 2 where n is the number of spatial units x i is the attribute value for feature i x j is the attribute value for feature j and w ij is the spatial weight between feature i and j modeling the associated factors of pods 241 variables dependent variables the number and proportion of individuals with disabilities serve to elucidate the connection between disability and socioeconomic and built environments it is important to highlight that the proportion of persons with disabilities signifies the prevalence of disability and can offer more insightful information when examined within microspatial units of cities considering the significant variation in total population sizes in this study we used total pods and different types of pods as dependent variables pods were calculated by determining the percentage of persons with disabilities per subdistrict relative to the total population independent variables to effectively address the challenges of disability prevention and rehabilitation it is imperative to have a comprehensive understanding of its associated factors building upon existing studies on the prevalence of disability 24 this study incorporates various socioeconomic variables per capita gdp serves as an indicator of overall economic conditions influencing resource availability services and support systems for individuals with disabilities the urbanization rate reflects the extent of urban development and population concentration in urban areas the elderly population rate was included due to the association between aging and a higher probability of disability and agerelated impairments moreover the migrant population rate was considered to explore the impact of factors such as language barriers cultural differences and limited resource access on the wellbeing and inclusion of migrants with disabilities the study also incorporates several built environment factors such as access to public services traffic density and access to disability service facilities these factors fall within the category of built environments which focuses on the services that directly impact the accessibility and quality of life for persons with disabilities basic public services encompassing education medical commercial and sports facilities are vital for ensuring equal opportunities and inclusion transport density influences mobility and access to employment education and healthcare facilities moreover public services specifically designed for persons with disabilities such as special schools nursing centers rehabilitation land 2023 12 1480 6 of 20 facilities and employment service facilities play a crucial role in promoting independent living and social participation a detailed description of variables is presented in table 1 and all variables were calculated at the subdistrict level to improve the distributional symmetry of the variables and mitigate potential heteroskedasticity issues a log transformation is applied to all variables ordinary least square regression is the minimum variance unbiased estimator which requires the random disturbance term of the ols regression to have a zero mean and be identically distributed additionally the error term must follow a normal distribution however de silva et al argue that these assumptions do not hold true in real economic life as the data for socioeconomic indicators may exhibit different distributional patterns 25 to overcome the limitations of ols analysis the quantile regression estimation method established by koenker and bassett jr is widely employed 26 there are three primary motivations for implementing qr estimation first qr does not require the presence of a moment function assumption second qr offers more accurate and robust findings in the presence of outliers and heavytailed distributions as demonstrated by bera et al 27 finally the qr method does not impose any distributional assumptions as noted by sherwood an wang 28 this study employs the qr approach to examine the associated factors of pods the quantile estimator is obtained by solving the following optimization problem as shown in equation min β∈r k   ∑ i iy i ≥x i β θ y i x i β ∑ i iy i ≥x i β y i x i β   for the quantile where y i is the dependent variable and x i is k by 1 vector of the explanatory variables results and discussion urbanrural disparities of pods spatial pattern of total pods in this study we employed the natural breaks method to examine the spatial distribution of the pods at the subdistrict level in tianjin as depicted in figure 3 the findings revealed that disabled individuals were predominantly concentrated in the urban center with only a handful of subdistricts on the urban periphery exhibiting substantial disabled populations in contrast rural areas generally displayed low pods moreover using getisord general g and getisord gi analyses we determined that pods demonstrated a significant spatial clustering pattern as illustrated in figure 3 the distribution of pods in tianjin displayed persistent concentration and relative dispersion with hotspots mainly situated in the urban core and a limited number of rural areas conversely cold spots were dispersed across the urban fringes and suburban rural areas urbanrural disparities of pods spatial pattern of total pods in this study we employed the natural breaks method to examine the spatial distribution of the pods at the subdistrict level in tianjin as depicted in figure 3 the findings revealed that disabled individuals were predominantly concentrated in the urban center with only a handful of subdistricts on the urban periphery exhibiting substantial disabled populations in contrast rural areas generally displayed low pods moreover using getisord general g and getisord gi analyses we determined that pods demonstrated a significant spatial clustering pattern as illustrated in figure 3 the distribution of pods in tianjin displayed persistent concentration and relative dispersion with hotspots mainly situated in the urban core and a limited number of rural areas conversely cold spots were dispersed across the urban fringes and suburban rural areas spatial pattern of different types of pods as illustrated in figure 4 the spatial patterns of different types of pods displayed noticeable urbanrural disparities the global spatial autocorrelation results demonstrated that the getisord general g value for all types of pods was greater than 0 and passed the significance test signifying the presence of spatial autocorrelation in this study spatial pattern of different types of pods as illustrated in figure 4 the spatial patterns of different types of pods displayed noticeable urbanrural disparities the global spatial autocorrelation results demonstrated that the getisord general g value for all types of pods was greater than 0 and passed the significance test signifying the presence of spatial autocorrelation in this study the hotspots for the prevalence of visual hearing and limb disabilities were situated in the urban center with pods exceeding 0033 0028 and 243 cold spots were located in urban fringes with pods below 05 03 and 45 the distribution of hotspots for the prevalence of mental disabilities was relatively dispersed with significant hotspots primarily concentrated in the urban center where the pods for all subdistricts was approximately over 29 and in remote rural areas with pods exceeding 17 for some subdistricts cold spots were identified in suburban rural areas with pods below 04 the hotspots for the prevalence of intellectual and speech disabilities were found in rural areas the prevalence of intellectual disabilities had significant hotspots mainly concentrated in suburban rural areas with pods exceeding 035 cold spots were identified in urban fringes with pods for most subdistricts below 005 the hotspots for the prevalence of speech disability were concentrated in urban fringes with pods over 007 and in the northcentral rural area with pods exceeding 011 cold spots were located in remote rural areas with pods below 002 overall podlimb was significantly higher than that of the other disability types while podspeech was notably lower the urban center and its neighboring areas were the primary hotspots for podvisual podhearing podlimb and podmental in tianjin with urban fringes being hotspots for podspeech and rural areas for podintellectual and podspeech the hotspots for the prevalence of visual hearing and limb disabilities were situated in the urban center with pods exceeding 0033 0028 and 243 cold spots were located in urban fringes with pods below 05 03 and 45 associated factors of pods associated factors of total pods qr was utilized to investigate whether socioeconomic factors and the built environment were associated factors of pods the results are presented in table 3 which reports the 10th 20th 30th 40th 50th 60th 70th 80th and 90th percentiles for the total pods and different types of pods for the total pods the ols result demonstrates that the impact of urbanization is negatively associated with pods and the qr results show an increasing trend from 0403 in the 10th quantile to 0366 in the 90th quantile although research by gong et al found that rapid urbanization in china was linked with an increasing disease burden this finding provides evidence of the potential advantages of urbanization on pods 29 it suggests that the benefits of urbanization such as improved access to healthcare sanitation and secure nutrition outweigh the negative impacts of issues like overcrowding pollution social deprivation crime and stressrelated illnesses medical facilities also emerged as a significant negative predictor of pods which is consistent with the disability and medical theory asserting that medical status is a critical determinant of disability 19 bus and road density were significant positive predictors of pods the rapid development of road traffic has increased traffic injuries in developing countries leading to a rising number of disabled individuals 19 migrant population positively impacted pods at the 30th60th quantile levels indicating that the migrant population increased pods in rural areas with midlevel pods rural migrants often engage in the informal economy such as construction transport and other manual labor industries which can result in injury instability and limb and mental disabilities 22 the qr coefficients of the elderly population were significant at the 70th90th quantiles suggesting that population aging increased pods in urban centers where life expectancy for elderly individuals is highest education facilities were negatively significant at the 80th and 90th quantiles implying that education levels reduced pods in urban centers these results confirmed that higher education levels help raise awareness of prenatal diagnosis and disease prevention which are closely related to the causes of disability dominant factors of different types of pods to examine the association between socioeconomic factors the built environment and different types of pods separate ols and qr analyses were conducted the study demonstrates significant heterogeneity in the impact of associated factors on various pod types most factors are significantly associated with specific pods only at particular quantile levels for the podvisual and podhearing ols analyses demonstrate that the coefficients of medical facilities had a significantly negative effect qr results indicate that the correlation is only significant at high percentiles the effect size decreased from 0069 in the 50th percentile to 0140 in the 90th percentile for podvisual and from 0188 in the 60th percentile to 0474 in the 90th percentile for podhearing respectively moreover the results of ols and qr indicated a positive correlation between public transportation and podvisual or podhearing notably for podhearing the correlation increased from 0089 in the 10th percentile to 0113 in the 80th percentile suggesting that it was gradually increasing with the growth of public transportation density for podlimb and podintellectual both ols and qr analyses demonstrate that the coefficients of urb have a significantly negative effect in the case of podlimb urbanization coefficients are higher in the low and high quantiles on the other hand for podintellectual urbanization coefficients are higher in the middle quantiles this suggests that urbanization reduces podlimb in urban centers and fringes as well as podintellectual in urban centers furthermore the ols results reveal that the elderly population increases both podlimb and podintellectual the qr results indicate significance at high quantiles suggesting that the effect of an aging population is more pronounced for higher levels of podlimb and podintellectual additionally the density of roads had contrasting effects leading to a decrease in podintellectual but an increase in podlimb finally qr results show that medical and education facilities decrease podlimb and podintellectual at middlehigh quantiles respectively for podmental and podspeech both ols and qr results reveal a significant positive correlation with the migrant population the coefficients of the migrant population increase across quantile levels indicating a stronger association between the migrant population and higher levels of podmental and podspeech for podmental study found that urbanization had a negative correlation with prevalence in the low quantile levels but a positive correlation in the middle to high quantile levels additionally the elderly population and bus and road density were significantly correlated with the increase in podmental at high quantile levels regarding podspeech density of bus stops has a significant negative impact on middle to low quantiles indicating that areas with lower bus density have higher levels of podspeech discussion urbanrural disparities of pods the spatial distribution of total pods in tianjin municipality showed significant urbanrural disparities with higher pods in urban centers these findings demonstrated that the majority of disabilities exhibited an urbanization phenomenon which contradicts some previous studies that reported higher pods in rural areas 30 the highdensity urban environment and serious aging trends in urban areas may contribute to the distinct distribution of disabilities and chronic diseases 31 it underscores the need to reevaluate the health implications of significant changes in urban and rural demographic structures and the rapid pace of urbanization 32 the prevalence of different types of disability varies across urban and rural areas indicating differences in the causes of disability between these settings contrary to previous conclusions podvisual podhearing and podlimb show significant accumulation in urban centers challenging the notion of rural dominance these findings suggest that ongoing changes in disability factors and trends will influence projections of incidence and disability prevalence 33 however the higher podintellectual and podspeech were still found in rural areas due to higher prevalence among children and adolescents associated with socioeconomic development 34 categories based on the dominant factors the study found that urbanization rate migrant population elderly population medical facilities education facilities bus route density and road density had significant impacts on pods with varying effects on different types of disabilities based on the dominant factors the six types of disabilities were categorized into three groups medicaldominated type the first type is medical facilitydominated which includes podvisual and podhearing according to the data from the second national sample survey of people with disabilities in tianjin the leading causes of visual disability were cataracts and retinal and pigment membrane lesions while the leading causes of hearing disability were presbycusis otitis media and systemic disease these diseases are agerelated and have become more prevalent as life expectancy has increased 5 however they can now be effectively treated or alleviated through medical and rehabilitation means 35 due to their unique communication and sensory needs and higher risk of chronic diseases individuals with visual and hearing impairments particularly older adults often require adequate medical facilities and care moreover as urban public transportation facilities become more accessible they can increase employment education and other opportunities improve the overall quality of life for those with sensory disabilities and reduce social isolation 36 consequently individuals with visual or hearing disabilities might cluster in areas with more developed public transportation facilities 37 urbanizationand agingdominated type in the second type urbanization and population aging predominate encompassing both limb and intellectual disabilities the 2nd national disability survey reveals that cerebrovascular diseases osteoarthrosis other injuries industrial accidents and traffic accidents are the primary causes of limb disabilities brain diseases and hereditary factors account for most intellectual disabilities it confirms that in advanced societies degenerative diseases such as cerebrovascular and brain diseases have supplanted nutritional deficiencies and infectious diseases as primary causes of death and disability 38 the prevalence of these diseases increases with age and urbanization improves access to healthcare facilities leading to significant reductions in disability rates 39 however urbanization was also associated with an increase in the migrant population which in turn led to an increase in podlimb this finding supports previous research suggesting that high rates of podlimb can be partly attributed to industrial accidents and other injuries resulting from informal employment 22 additionally road density had divergent effects on podintellectual and podlimb this highlights the importance of road traffic development in rehabilitating intellectual disabilities however it also confirms the higher rates of traffic accidents observed in developing countries which contribute to an increased prevalence of limb disabilities 40 furthermore the results indicate that medical facilities are associated with a decrease in podlimb consistent with previous findings on improved medical conditions reducing osteoarthrosisrelated disability rates educational facilities are linked to a reduction in podintellectual potentially due to improved medical knowledge through enhanced education in rural areas including better prenatal care to mitigate hereditaryrelated intellectual disabilities 41 migrantdominated type the third type is characterized by a migrant population and encompasses both mental and speech disabilities the 2nd national disability survey identifies schizophrenia and dementia as the primary causes of mental disabilities while cerebral infarction and hearing impairment are the leading causes of speech disabilities this is in line with previous research suggesting that factors such as environmental stressors language barriers discrimination and social isolation may lead to higher mental illness rates among migrants 42 migrants who often have temporary residence and frequent relocation may face higher speech disability risks than permanent residents while no conclusive evidence links language disabilities to this population research indicates that lifestyle differences and limited healthcare access including health insurance may contribute to increased risk factors like migrant status unstable residence and limited healthcare resources may further exacerbate this vulnerability furthermore several additional factors have been identified as being linked to mental disability firstly higher natural environmental exposure is associated with better mental health outcomes while increased urbanization may elevate the risk of mental illness 43 secondly studies have consistently shown a positive correlation between the elderly population and mental disabilities which can be attributed to chronic health conditions social isolation and cognitive decline 44 moreover transportation factors are also linked to mental disabilities the results support previous research indicating that living near busy roads may increase the incidence of mental illness due to air pollution compared to quieter areas 45 additionally exposure to public transportation and car traffic has been found to raise the risks of anxiety and depression potentially stemming from low satisfaction with public transportation 46 in the context of speech disability it has been found that areas situated on the urban fringes or rural areas are negatively affected by bus density this can result in reduced mobility for individuals with speech disabilities due to factors such as noise pollution traffic congestion and limited accessibility these difficulties can contribute to communication barriers which in turn may lead to increased social isolation conclusions and policy recommendations although there is a certain awareness of disability in the field of healthcare the spatial distribution of the prevalence of disability within chinese municipalities remains relatively underresearched this study uses aggregated registration information from the tianjin disability database 2020 to identify urbanrural disparities in pods additionally it investigates the heterogeneous impacts of socioeconomic and built environment variables on different types of pods the methodological approach employed in this study can serve as a framework for conducting comparative studies in other regions or countries researchers can adapt and apply our methodology to different geographic contexts to explore the associations between disability and relevant factors in those specific areas by employing a similar approach these studies can gain valuable insights into the unique challenges and opportunities related to disability in diverse sociocultural settings furthermore the findings of this study have implications for policy and urban planning aiming to improve accessibility and inclusion for individuals with disabilities policymakers and urban planners can use the research outcomes to identify priority areas and develop targeted interventions addressing specific needs and promoting inclusivity to enhance wellbeing first the spatial distribution of total pods in the tianjin municipality showed significant urbanrural disparities with higher pods in urban centers this finding contradicts previous studies in developing countries which found higher pods in rural areas 6 and prompts the global south to reexamine the health implications of dramatic changes in urban and rural demographic structures and rapid urbanization 29 similarly podvisual podhearing and podlimb also exhibit significant urban center accumulation contradicting previous conclusions indicating rural dominance 8 this suggests that current changes in disability factors and trends will impact projections of incidence and disability prevalence 33 second urbanization rate migrant population elderly population medical facilities education facilities bus route density and road density significantly impacted pods and had heterogeneous impacts on different types of pods this study summarized them into three categories based on the dominant factors medical facilitydominated urbanizationand agingdominated and migrantdominated these categories are closely related to the socioeconomic and built environment differences between urban and rural areas behind various types of disability adequate medical facilities and care benefit functional disabilities 47 such as visual and hearing disabilities while having weaker impacts on cognitive disabilities such as intellectual and mental disabilities rapid urbanization has a dual effect on disability improved access to healthcare sanitation and secure nutrition benefit intellectual and limb disabilities while overcrowding pollution social deprivation crime and stressrelated illnesses exacerbate mental and speech disabilities 48 the increased pods due to aging are confirmed 49 particularly in intellectual and physical disabilities and visual and hearing disabilities in urban centers inequalities in healthcare education and social isolation faced by migrant populations have increased the prevalence of some types of disability providing new empirical research for social models of disability 20 our results have important policy implications for the spatial governance of disability first focusing on the sharp increase in disability burden in the context of an aging population specific services should be provided to the elderly in various areas including disease prevention treatment disability rehabilitation and care second despite the high availability of medical services in urban centers gaps in health service provision related to the surge in disability prevalence will persist strengthening medical service provision in urban centers could curb this surge third specialized clinics and rehabilitation institutions should be established for individuals with intellectual and psychological disabilities in rural areas to meet their urgent needs for early rehabilitation and longterm treatment finally for migrant populations especially rural migrant workers vocational training should be strengthened and working conditions and social security should be improved to reduce the risk of occupational disability and social isolation 50 this study has limitations first this study relies on crosssectional data and cannot demonstrate the changing pattern of the prevalence of disability over time vertical crosssectional studies with time spans will play a greater role in exploring the spatial and temporal patterns of disability and changes in disabling factors second because of the availability of data the selection of socioeconomic variables still has some limitations more variables such as income level birth rate etc will be added to future studies thirdly to ensure overall data availability the study was conducted at the subdistrict level albeit with the compromise of certain data such as access to public facility however it is acknowledged that conducting the study at a more detailed spatial unit would enhance its accuracy furthermore although the current singlecity study is more detailed in the spatial unit it does not fully represent the overall prevalence of disability in chinese cities future studies should select multiple types of cities of different sizes for comparison data availability statement the data cannot be made available due to confidentiality reasons

in the current context of aging and urbanization the rapid increase in the prevalences of disabilities pods has become an important consideration in healthy urban planning previous studies have focused on the spatial prevalence of total disabilities based on largescale survey data however few studies have examined different types of pods and the factors contributing to spatial disparities in microurban units at the municipal level this study aims to fill this gap by exploring the spatial pods related built environments and socioeconomic factors across the tianjin municipality in 2020 the study employed getisord gi analysis to identify urbanrural disparities and ordinary least square ols and quantile regression qr analyses to model the heterogeneous effects of the spatial podsassociated factors across quantiles the results reveal that the pods especially of visual hearing and limb disabilities in the urban center are significantly higher than those in rural areas which is inconsistent with previous studies conducted in china the urbanization rate medical facilities and education facilities significantly reduced the total pods while the elderly population migrant population bus route density and road density significantly increased it the built environments and socioeconomic factors had heterogeneous impacts on different types of pods which were summarized into three categories based on these dominant factors 1 visual and hearing disabilities were medical facilitydominated 2 intellectual and limb disabilities were urbanizationand agingdominated and 3 mental and speech disabilities were migrantdominated this study provides scientific advice to adapt to the expected increase in demand for disabilityrelated medical and public health services and to expand the range of effective strategies and interventions aimed at preventing the deterioration of disability and improving disability management in the population

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introduction correctional facilities worldwide are considered environments for fast and uncontrolled spread of blood borne viruses such as human immunodeficiency virus and hepatitis b virus and many other infectious diseases due to specific risk practices poor health care and living conditions 1 2 3 globally there is a gross disproportion in rates of infection among isolated populations such as seen in prisons and the general population 4 5 6 7 many studies in subsaharan africa and in ghana have revealed that the prevalence of bbvs in the general population is lower than that among highrisk groups 38 those at highrisk include blood or tissue donors haemodialysis patients hivpositive patients household members or sexual contact of infected individuals individuals with conditions that may require immunosuppressive or immunemodifying therapy infants born to hbvinfected mothers injection drug users men who have sex with men and pregnant women 9 10 11 12 13 14 15 among these highrisk groups injecting drug users and men who have sex with men are said to be more common among incarcerated populations 2 16 17 18 19 it is well known that behaviours such as sex tattooing and injection drug use are illegal at the prison sites but these are the most prevalent intraprison highrisk behaviours that put inmates at risk of bloodborne infections including hiv and hbv which may account for the higher prevalence in the prisons 19 international data suggests that the prevalence of hiv among prisoners may be three to fifty times higher than in the general adult population 8 20 21 22 23 relatedly hbv prevalence within prisons in ghana are higher than the national prevalence 3 according to statistics for the year 2013 from the ghana prisons service there are fortytwo prison establishments nationwide who at the time had a population of approximately 13908 inmates this consists of approximately 10886 convicted and 3023 prisoners who were yet to be convicted the majority of which were men 24 there were only about 217 women and 117 juveniles 24 antiviral therapy for both hiv and hbv as well as vaccines to prevent hbv disease are currently available in ghana it is therefore important to identify risk behaviours associated with infections within correction facilities in order to develop protocols and also to link infected prisoners to therapy this study was part of data collected from a behavioral and health survey conducted in ghana from the month of february to march in 2013 the prevalence and risk factors associated with hiv and hbv infections were determined and implications for the treatment and eradication of both infections discussed methods and materials study design a crosssectional design employing quantitative methods were used to assess the situation of hiv and hbv infections as well as other key noncommunicable illnesses among prison inmates intervieweradministered standardised behavioural questionnaires for inmates were used to assess the situation in the prison and determine potential risk factors at one point in time relying on participants recall of their behaviour before and during imprisonment the study integrated results from the biological tests with the behavioural questionnaires covering inmates knowledge attitudes behaviours and environmental factors sampling and administration of questionnaire the study consisted of male and female prison inmates on remand awaiting trial convicted and sentenced sampling was done at all locations and for all categories of male prisons for the females only one medium security prison and six local prisons were included a census was conducted of all 260 female inmates scattered across seven prison locations who consented to be part of the study a stratified random sample was taken of the male prison inmates all inmates were 18 years and above nationally the sample size required for a simple random sample of 13500 prisoners is 1842 using 1 standard error adjusting for the provision of an estimated 80 response rate the sample size was increased to a total of 2238 male inmates a total of 2443 prisoners were successfully enrolled and interviewed comprising 205 female and 2238 male inmates proportionate sampling relative to the population of each category was conducted and respective sampling intervals were computed and applied appropriately to the various categories at each prison station the purpose and the various procedures involved in the study was explained to all selected participants thereafter interviews were conducted between 2025 minutes in the open but in isolation from other participants and interviewers to ensure privacy and confidentiality the questionnaire consisted of seven sections as follows sociodemographic the interview was administered in either english or appropriate local language at the end of each interview participants were issued a counselling and testing card to enable tracking of participants through all testing procedures the questionnaire was pretested involving 20 inmates at winneba prison which was not part of the sample the pilot study was to assess whether the questions were clear and easy to understand and also examine whether the listed categories of answers catered for all possible responses amendments were made to the questionnaire subsequently at each prison station the purpose and the various procedures involved in the study was explained to all selected participants thereafter interviews were conducted between 2025 minutes in the open but in isolation from other participants and interviewers to ensure privacy and confidentiality the questionnaire consisted of seven sections as follows sociodemographic characteristics prison environment health in prison hiv riskblood contact hiv riskinjecting drug use hiv risksexual contact and hivaids knowledge and attitudes the interview was administered in either english or appropriate local language at the end of each interview participants were issued a counselling and testing card to enable tracking of participants through all testing procedures the questionnaire was pretested with 20 inmates at winneba prison which was not part of the sample the pilot study was to assess whether the questions were clear and easy to understand and also examine whether the listed categories of answers catered for all possible responses amendments were made to the questionnaire subsequently diagnostic procedures and counselling well trained biomedical personnel and a professional hivaids counsellor for testing and counselling respectively carried out this component preand postcounselling was done on oneonone basis the weight and height were measured using standard anthropometric procedures for measuring adults and bmi was calculated thereafter 35 ml sample of blood was taken using a 5ml edta vacutainer tube the blood was thoroughly mixed by gently swirling and turning tubes upside down 15 times and placed in a rack following manufactures instructions as described in the test protocol hiv was confirmed using the firstresponse hiv12 as an initial test and oraquick rapid hiv12 antibody test as a supplemental test plasma from the edta tubes was used to test for the hepatitis b surface antigen was detected concurrently with wondfo one step hbsag test and core tm hbsag in both algorithms the two screening tests had to be reactive to confirm hiv and hbv infections after rapid testing in the prisons blood samples in their vacutainer tubes were transported on ice packs to the nearest regionaldistrictghana health service laboratory aliquots of plasma were stored at 28˚c for 35 days after which they were transported on ice packs to the clinical virology laboratory department of medical microbiology university of ghana for permanent storage at 20˚c data management and statistical analysis completed questionnaires were reviewed twice a week by field supervisors to ensure consistency and check for any reoccurring errors the results from the diagnostic tests were recorded directly onto the anonymous coded questionnaires to ensure that there was no misallocation between the behavioural and biological data data from the questionnaires were entered and analysed by the statistical package for social sciences version 180 software the data entry was independently verified and cleaned by a second investigator bivariate analysis was conducted to determine whether there were significant associations between inmates hiv hbv bmi and their gender age education length of imprisonment type of prison risk behaviours and knowledge of hivaids given the risk that bivariate associations can be confused by confounding factors a multivariate analysis using logistic regression was also carried out to establish ultimately which factors were significantly associated with inmates hiv and hbv prevalence the pearsons chisquare test was used to assess the association between prisoners characteristics and their hiv and hbv status the simple binary logistics regression model was used to estimate the crude odds ratios of both hiv and hbv positivity across the various characteristics of the prisoners the multiple binary logistic regression model was then used to estimate the adjusted odds ratios of hiv and hbv positivity across the various characteristics of the prisoners the fischers exact chisquare test was used to assess the association between inmate characteristics and prevalence of both hiv and hbv positivity among the prisoners the frequency and percentage distribution of both hiv and hbv positivity were described across the various categories of the characteristics of the inmates ethics approval for the study was obtained from the noguchi memorial institute for medical research institutional review board and the ghana health service ethical review committee prior to the study two levels of written signed consent for the survey and blood specimen banking were obtained during the period of obtaining informed written consent from the inmates they were made to understand that their participation was voluntary and that they were free to opt out of the study results characteristics of study participants a total of 2443 prisoners were interviewed in the study with a median age of 31 years 26 to 40 years most of the prisoners were between the age range of 2029 years with 124 above 59 years two thousand two hundred and thirtyfour of the prisoners were males 428 had no formal education whilst 94 had college or university level education threequarter were christians 1035 had never married whilst 1129 were currently married majority were convicted prisoners whilst 380 were on remand majority of the prisoners had normal weight 643 were hypertensive 1694 had ever use drugs and about a third had been in prison for the current sentence or remand for less than a year detailed characteristics of the prisoners are shown in table 2 prevalence of hiv and hbv among inmates among the 2436 prisoners who had hiv test results 58 furthermore 313 of the 2442 prisoners that had hbv test results were positive only 5 of the 2435 who screened for both hiv and hbv had coinfection hiv status and associated characteristics the frequency and percentage positivity and negativity were also described across the prisoners characteristics from the pearsons chisquare test age was found to be significantly associated with the hiv status of the prisoners with hiv positivity of 15 among those age 1819 years 13 among those aged 2029 years 27 among 3039 years old 44 among 4049 years old 31 among 5059 years old and 24 among those 60 years and above prevalence of hiv was significantly higher among female prisoners than among male prisoners from pearsons chisquare hiv positivity was significantly higher among those who were divorced separated or widowed compared to those who had never married or those who were currently married from the pearsons chisquare test prevalence of hiv was also significantly higher among obese prisoners compared to those underweight those with normal weight and those who were overweight from the pearsons chisquare test prevalence of hiv was significantly higher among prisoners who have never used drugs compared to those who had ever used drugs from the pearsons chisquare test prevalence of hiv was significantly higher among prisoners who have been in prisons for less than a year for their current conviction or remind compared to those with 15year stay and those with more than 5 years stay from the pearsons chisquare test binary logistic regression model of factors associated with hiv status among inmates from the multiple binary logistic regression model the adjusted odds of hiv positivity was 82 less among male inmates than females also for prisoners who have currently been in prison for less than a year for their current sentence or remand the adjusted odds of hiv positivity was 93 less among those who have been in prison for more than 5 years overall the time served for current sentence or remand was found to be a significant factor associated with hiv status of prisoners hiv status and sexual behavioural characteristics sexual risk behavioural experiences of inmates before imprisonment such as casual sex partnerships and sex with commercial sex workers and forced penetrative sex within prison with other inmates were examined with hiv prevalence among prisoner hiv prevalence was 28 among those who had never engaged in casual sex partners compared with those who reported casual sex among those who reported casual sex prevalence was highest amongst those who reported inconsistent condom use similarly hiv prevalence is higher among inmates who reported they had never engaged in sex with commercial workers compared to 14 among those who had ever done so there was no statistically significant difference in condom use among inmates who had ever had sex with csws hbv status and associated characteristics the prevalence of hbv was highest in inmates between the ages of 2029 years and lowest among those above 59 years there were significant differences in prevalence between the various age groups the prevalence of hbv was significantly higher among male inmates compared to females there were varying degrees of prevalence among the various levels of education hbv positivity was significantly higher among inmates who had never married compared to those who were currently married and those who were divorced separated or widowed details of the association between characteristics and hbv status are shown in table 5 binary logistic regression models of factors associated with hbv status among inmates compared to inmates with no formal education the adjusted odds of hbv positivity was 35 less among inmates with primary level of education also compared to inmates who were underweight the adjusted odds of hbv positivity was 49 less among inmates who were obese hbv status and sexual behavioural characteristics this study examined the relationship between selected sexual risk behaviours of inmates before and during incarceration and being tested positive for hepatitis b infection table 6 shows that none of the sexual behavioural characteristics were significantly associated with hepatitis b infection though varied proportions were reported for instance almost equal proportions of inmates had or had not engaged in casual sex partners however in terms of risk those who reported they never used condoms in their casual sex engagements were least infected with hepatitis b as opposed to those who used condoms consistently a similar result was found for sex with csws and condom use where inmates who reported consistent condoms ware most infected with hepatitis b hiv and hbv coinfection only 5 of the 2435 that had both hiv and hbv conclusive test results were both hiv and hbv positive representing 021 hence a 95 confidence interval of both hiv and hbv positivity in prisons in ghana is estimated from 007 to 048 discussion generally the results of this study suggest significant hiv and hbv infections in prisons in ghana to our knowledge this is the first nationally representative biobehavioural survey of hiv and hbv infections and other key health problems of prison inmates in all categories of prisons across ghana according to this study the overall hiv and hbv prevalence among prison inmates in ghana in the year 2013 was 238 and 1282 respectively with vast variation based on region and sex there generally seems to be a decreasing trend with increasing age with regards to hbv prevalence however with hiv infections no such observation was made albeit with much lower prevalence rates similar numerical hiv prevalence rates were seen in the general population as compared to the male prison inmates however a much higher prevalence than in the general population was observed in the female prisoners as compared to the general population 25 the latter may be accounted for by the higher national prevalence in women than men and an also smaller population size than the male inmates the study provided detailed hiv prevalence within prisons in the various geographical locations in ghana brong ahafo region and central region recorded the highest hiv prevalence which was numerically higher than what pertains in the general population of these two regions 2627 the northern region on the other hand recorded the lowest which correlates with the 1 prevalence in its general population 26 the hbv prevalence as represented by the presence of hbsag was numerically similar to the estimated national prevalence of 123 28 systematic reviews and metaanalysis done covering the same time period estimated the national prevalence to be 102 2829 the current study also provides data to fill national gaps on hbv infection in the volta western upper east and upper west regions 2829 trends for hbsag infections are generally expected to reduce with infant vaccination which began in 2002 30 this does not seem to reflect in the data obtained for this study those within the 1819 year group had relatively higher hbsag prevalence than the than the other age groups since few hbsag positive children were seen in a study in children 5 years done in 2013 31 it is possible that these male inmates may have had low vaccination coverage alternately antihbs may have waned for hbv infection to occur in contrast to hiv those with hbv infections may agree with data obtained from different population in ghana 28 these may suggest that there may have been similar rates of hiv and hbv infections within the prisons as compared to the general population this is at variance with a previous study done about a decade ago which suggested that hiv seropositivity was significantly associated with hbsag detection in ghanaian prisoners 32 the high prevalence seen in that study seems not to have been replicated in this study it is important to note that the assays used were not the same as what was used this study 28 on the whole hiv and hbv infections in prisons may have reduced between 2005 to 2013 based on the data acquired from this study and another conducted by adjei et al 3 the reduced hiv prevalence determined by this study may also have been affected by sample size as seen in a fairly recent study in zambia 33 generally there seems to be comparatively limited data on hbv infections in correctional institutions in africa on the other hand hiv prevalence in african prisons has been generally high with up to a prevalence of 177 in south african prisons 2034 however a much more recent study which systematically assessed publications on hiv prevalence among inmates from four different african countries reported an average prevalence of 6 35 this may suggest that hiv prevalence in correctional facilities on the continent and in ghana may be on the decline 2023333536 a randomised sample of 600 prisoners conducted in senegal reported an hiv prevalence which was four times higher than the national rate 23 prisoners enrolled in this study have had sexual encounters while in incarceration with 178 being in multiparter relationships only 46 of the prisoners who were drug users before incarceration admittedly were still on drugs after imprisonment 23 there is no doubt that highrisk behaviours are a key contributing factor in the spread of bloodbourne viruses such as hiv and hbv in correctional facilities as suggested by several studies around the world 1718222337 however the absence or low incidence of such highrisk behaviours have also been evidently associated with a reduced prevalence of hiv in prisons based on our study even though hiv and hbv have similar routes of transmission 38 39 40 for both hiv and hbv infections exposure to forced penetrative sex approached significance in addition individual inmates hearing about other inmates being forced for penetrative sex was significant for hiv but not hbv infections it seems that the issue of forced sex is a problem in the prisons but the inmates may not have truthfully responded to the questionnaire for due to the cultural disdain for such practices this may explain why being female and staying in the prison for more than 5 years increases the risk of having hiv infections these observations have been made in other studies and may not be new to the prison environment 41 feeding in prisons in low to middle income countries is a chronic problem 42 with increasing length of stay therefore inmates are likely to become emaciated this may be associated with low immunity and less ability to fight disease it is therefore not surprising that those who were without formal education and had stayed longer in prison were those who were likely to have hbv infection the outcomes of the effects of the sexual behavioral variables on hiv and hbv infections and the prevalence rates therefore suggests that these two viruses may still be transmitted within the prison but not to the extent resulting in very high prevalence as previously seen 3 perhaps the movement of remand prisoners may partly account for the observation there is evidence to supporting the existence of highrisk activities that fuel the transmission of hiv in prisons in other jurisdictions for example idu is a key route of hiv transmission in prisons 38 but there was no significant evidence of idu use in ghanas prison the most common drugs used in the prisons were marijuana and valium 43 hiv was higher in the maximumsecurity prison where most freedoms and contacts between and among inmates are restricted than in the local and central prisons however there was no evidence to conclude that these inmates were infected within incarceration further tests are needed to confirm how long hiv positive inmates have been living with the virus to be able to establish whether inmates were infected prior to imprisonment or not voluntary hiv and hbv testing could be offered new inmates to identify those infected and to offer them the help and support needed it may be necessary to institute and intensify care and support programs for hiv and hbv in the prisons to reduce spread within the prisons and less likely transmission when they are discharged as part of the 959595 plan to eradicate hiv 44 selftesting may have to be introduced in the prisons for hiv and mandatory hbv vaccination for those who are entering with a median age of 31 years in means that incarceration may be more associated with the young those who were vaccinated at birth as part of ghana epi programme will therefore be edging towards the median age which may hopefully reduce those susceptible for hiv infections health education in prisons should address the modes of transmission of hiv and hbv conclusion at the time of the study the hbv prevalence in the prisons was almost similar to that of the general population this suggests that the level of transmission within the prisons then may not have resulted in high transmission patterns different from the general population nevertheless the issue of forced penetrative sex must be addressed and appropriate care programmes instituted to protect and treat inmates with hiv and hbv infections instituting screening at entry to create a database may be of help to the country all relevant data are within the paper

previous studies have suggested high immunodeficiency virus hiv and hepatitis b virus hbv prevalence in prisons in ghana however this study was part of a nationally representative biobehavioural survey and determined the prevalence of hiv and hbv among prison inmates and identified factors associated with these infections both biomedical and behavioural data were collected from a total of 2443 prison inmates from 19 prison stations during 2013 in ghana 12 male prisons and 7 female prisons selected across the country the national hiv screening algorithm was used for hiv testing while two rapid detection tests were used to confirm hbv infections hiv and hbv prevalence among prisoners in ghana were approximately 234 and 1238 respectively only 5 inmates had coinfection with both viruses the prevalence of hiv was significantly lower among male inmates 15 compared to the female inmates 118 age sex and marital status were significantly associated with both hiv and hbv infections however bmi category idu and time spent in prison were associated with hiv infections the educational level was significantly associated with hbv infections after binary logistic regression being female aor 018 95 ci 007045 p 0001 and having a stay of 5 years or more aor 007 95 ci 001060 p 0016 increased the risk of having hiv infection while those with no formal education aor 065 95 ci 045095 p 0024 and are underweight aor 051 95 ci 027099 p 0046 were more likely to have hbv infection forced penetrative sex may be a problem in the prisons the need to have and strengthen an integrated screening treatment and vaccination plan for the prison is emphasized the prison does not serve as an exceptionally high risk to the general population the findings support a critical look at the issue of forced penetrative sex in the prisons

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repeated measurement of these factors contributed only to modest improvement in explanation further comparative research on the relative importance of explanatory pathways assessed over time is needed introduction socioeconomic inequalities in mortality can to a certain extent be explained by variation in health related risk factors according to current theoretical explanations these risk factors are related to material psychosocial behavioral and known biomedicalbiological groups of factors 1 2 3 4 in previous research several studies quantified the contribution of the respective risk factors to help explain social inequalities in health findings ranged from 12 to 54 for behavioral factors 356 and 73 to 83 for a combination of all above mentioned factors 4 in most studies however the risk factors have only been assessed at one time point however according to previous research health behavior and other risk factors can change over time and this change might be socially patterned 7 8 9 10 11 for example socioeconomically disadvantaged groups might have limited resources to adopt healthy lifestyle their mental health may deteriorate over time due to experiencing more adverse life circumstances their social network might be less supportive and their physical health might be more influenced by lasting unhealthy behavior as compared to socioeconomically affluent groups 7 8 9 10 11 in addition mortality health behavior and risk factor differences between men and women may also be apparent 11 12 13 men are more likely than women to have unfavorable levels of risk behaviors eg heavy drinking 1415 on the contrary women show higher levels of obesity 16 furthermore change in behavior may also be gender specific in 1980 s norwegian men had higher prevalence in smoking than women however over time mens prevalence of smoking declined while women experienced an increase in smoking in all socioeconomic groups 17 given changes in health behavior over the life course it is plausible that assessment of change in risk factors over time might provide more accurate information about the varying impact of explanatory mechanisms 18 for example assessment of timevarying behavior risk factors might result in a larger part of social inequalities in mortality being explained as compared to measurement at baseline only 19 but the magnitude of the explained share might vary according to cultural context and social patterning of risk factors 20 previous studies have assessed how change in behavioral 19 psychosocial 2122 and biomedical factors 823 and employment 24 affect explanation of socioeconomic inequalities in health however to the best of our knowledge no study has compared how accounting for change over time of different groups of explanatory factors together can contribute to explanation of social inequalities in mortality the aim of this study is thus to compare to what extent can education and income inequalities in mortality be explained by four groups of explanatory factors in men and women separately assessed at two time points as compared to baseline methods we combined data from two waves of the norwegian total county population hunt 1 and hunt 2 study 25 the hunt study has been considered to be generally representative for the norway as a whole 26 in hunt 1 all residents of the nordtrøndelag county aged 20 and over were approached number of respondents was 74 599 we included persons aged 25 to 80 years in the current analyses the lower age limit was set in order to have respondents completed education recorded people with missing information on education were excluded and those who reported history of health problems these diseases were assessed as a simple question in the health survey by selecting relatively healthy people for the analysis we aim to reduce the possibility of reverse causality given that sick people might change their behaviour this left a sample of 29 776 men and 31 747 women which provided information for the baseline risk factors measured in 198486 from this sample 22 781 men and 25 536 women participated also in hunt 2 and provided information on explanatory risk variables at the second time point during the mortality followup period 10 267 men and 9 404 women died in the period 19841995 3 748 men and 2 687 women died and in the period 19962009 6 519 men and 6 717 women died the linkage of the sample to the national death registry 27 together with data on education which were measured only at baselinewas provided and administrated by statistics norway the linkage between the data sources was made possible by a unique personal identity number which is given to every citizen in norway these linkages have been approved by the norwegian data inspectorate and the current study was approved by the regional committee for medical research ethics in middle norway all participants signed a written consent to take part in the study and have a standing opportunity to withdraw their consent at any time the data can be applied for at the ntnu hunt research center 25 socioeconomic variables the most often used measures of socioeconomic position include education occupation and income 9 since 34 of women could not be classified according to the egp occupational classification we focused only on education and income these measures are related but refer to distinct aspects of socioeconomic position and their relation to mortality might tap in different causal mechanisms 28 by employing both measures in the analysis one might be able to compare how different aspects of socioeconomic position affect mortality through presumably different pathways we used the norwegian national education data base as the primary source for the highest education attained rather than the hunt data the reason for this was the high number of cases of missing data in hunt 1 attributable to a high rate of nonresponse to part of the questionnaire including the question on education which was to be returned by postal mail the indicator was based on the national census in 1970 and subsequent information from schools updated until 1985 we reclassified the education data into three levelsprimary and lower secondary upper secondary and tertiary wherever possible missing nudb data on education were replaced by information on education from the hunt questionnaire however we had no information on education from either nudb or hunt and these persons were excluded from the analysis the income variable stems from norwegian tax authorities data on individual pensionable income and was calculated as the average of three subsequent data on income income quartiles were created separately for men and women based on income distribution in the whole hunt survey as the income distribution is dissimilar between sexes the lowest quartile category comprises also people with no income and retired pensioners without additional income the quartile with the highest income was the reference category risk factors behavioural factors were measured by information about smoking alcohol consumption and physical activity physical activity measured in two questions was scored with number of hours per week spent on activity type hard physical activity was given twice as much weight as slight physical activity persons missing information on either hard or slight physical activity were assigned the modus value of activity typical for persons who performed the same amount of the nonmissing activity based on psychological models which integrate stress and resources into explanatory pathways of the seshealth relation following psychosocial measures of social support and negative emotionswellbeing were included civil status feeling lonely and three measures on a 7 item likert scale feeling tired feeling unsatisfied and feeling unhappy example of a question is on the whole do you feel strong and in a good mood or tired and exhausted employment status was coded in four categories the last category also included low prevalent categories of military serviceeducation biomedical factors included bmi measured in three categories and hypertension defined as having systolic blood pressure 140 mmhg andor diastolic blood pressure 90 mmhg statistical analyses discrete time survival analysis 29 was applied to analyse mortality data where survival times were grouped into discrete intervals of time this data set up makes it possible to include change in timevarying variables age adjusted odds ratios for levels of education and income respectively were calculated by means of discrete time logistic model separately for men and women since there was a significant interaction between income and gender although there was no significant interaction between gender and education we also conducted separate analysis of education by gender for reasons of consistency all analyses were thus conducted for men and women separately ors were calculated for men and women aged 2580 years and also for two age subgroups age adjusted mortality rates per 100 000 personyears employing direct standardization in 5 years age intervals for each level of socioeconomic position were calculated separately for two age groups age adjusted ors were calculated for all baseline risk factors separately adjusted first for education and second for income and age standardized differences in risk factor prevalence between primary and tertiary educated and between lowest and highest income quartile were estimated employing 10 years age intervals in the main analysis we used the above mentioned associations between education and income and mortality adjusted for age as a reference model in all regression analyses age was accounted for as a continuous measure and as age squared next we adjusted for behavioural psychosocial and biomedical factors separately followed by adjustment for all explanatory factors simultaneouslyfirst for baseline explanatory factors and second including repeated measurement for each model the percentage change in ors of each level of education and income respectively was calculated 4 the fit of the models were assessed using 2loglikelihood test and the aic and bic criteria the analyses were done for men and women aged 2580 years the analyses were run using stata mp 112 we conducted also several sets of sensitivity analyses first we repeated the main analysis for men and women aged 2559 and 6080 years respectively second we extended the main analysis to respondents who were originally excluded due to history of disease while controlling for morbidity third we excluded persons who died before the second survey finally we also conducted another analysis restricted only to respondents with complete data results education and income were associated with mortality and followed a stepwise gradient in men or for mortality was 141 for primary education and 129 for secondary education and for lowest through second highest income quartile ors were 159 131 and 117 respectively in women only lowest education or 135 and lowest and next lowest income quartile with or 140 and 115 respectively showed significantly greater or as compared to their reference categories education and income inequalities in mortality were generally smaller in older people than in younger ages all risk factors increased risk of mortality for men and women after adjustment for either education or incomewith a few exceptions in men categories of homemaking and abstainers were not significantly different from their respective reference categories moderate exercise in men with or 093 showed to be protective compared to very active when controlled for education while there was no significant difference between those two categories when adjusted for income in women moderate exercise did not increase the risk of mortality compared to very active when adjusted for income neither abstinence widowhood unemployment nor homemaking in women was significantly different from their respective reference categories in respect to mortality in men largest differences in prevalence of risk factors between lowest and highest education were in physical activity and smoking while with regard to prevalence differences between lowest and highest income differences in psychosocial factors were most pronounced over time differences in prevalence according to education increased or remained the same for all factors except for physical activity hypertension loneliness unhappiness and tiredness which decreased differences by income decreased or remained on the same level with an increase in differences by former smoking inactivity and abstinence in women largest prevalence differences between lowest and highest education were in homemakers moderate smoking physical activity and obesity the largest prevalence differences between women with lowest and highest income were in tiredness and obesity over time differences in prevalence according to education decreased or remained the same with an increase in moderate smoking extensive alcohol unhappiness widowhood obesity and hypertension prevalence differences in women by income also decreased over time with a few exceptions in increase in heavy and former smoking physical activity and widowhood in men behavioural and psychosocial factors explained the largest proportion of mortality risk for low educated at the baseline when we accounted for change of these factors over time explained proportion reached 39 and 29 respectively all groups of risk factors explained together 54 of the excess mortality risk in low educated and 63 when accounting for change over time in income inequalities in mortality psychosocial factors explained a larger share than behaviour however over time change in psychosocial factors improved the explanation of income inequalities in health by only 1 while change in behaviour amended the explanation by 8 when change in all explanatory factors was accounted for 59 of excess mortality in low income group was explained compared to 54 by all explanatory factors at baseline the aicbic statistics suggested that models accounting for change in biomedical factors and employment had worse fit than models employing baseline measurement whereas the fit of all the other models accounting for change was better compared to baseline models in women behavioural and employment factors explained most of the excess mortality risk in low educated and all risk factors together explained 69 however when accounting for change in all the risk factors explained proportion of excess mortality reached only 57 both employment and biomedical factors contributed to such decrease this was also confirmed by the aicbic statistics suggesting worse fit of the models accounting for change in employment and biomedical factors as compared to models with respective baseline measurements however the fit of the model accounting for change in all risk factors had still better fit than the baseline model mortality risk of lowest income in women could be best explained by biomedical factors at baseline and by behavioural and psychosocial factors at follow up behaviour provided the largest increase in explanation at followup compared to baseline all baseline factors together explained only 18 of income inequalities in mortality and 25 when accounting for change models accounting for change had better fit than the baseline models according to aicbic except for the model employing biomedical factors additional analyses in the first sensitivity analysis we found that in people under 60 years of age baseline factors accounted for larger explanation of health inequalities than baseline factors in older people however when risk factors were measured over time nominal change in explanatory share was relatively larger in the age group over 60 yearswith larger increase in explained share by psychosocial and behavioural factors and a larger decrease in explanatory share by biomedical factors and employment in older people compared to the younger population in order to diminish possible reversed causality 93 of respondents were excluded from the analyses due to selfreported history of disease since these diseases are more prevalent in low socioeconomic positions a larger group with low education and income has been filtered out a sensitivity analysis employing all respondents and controlling for morbidity revealed that the adjustment for diseases resulted in smaller socioeconomic inequalities and a slight overestimation of the explanatory share by risk factors we also conducted a sensitivity analyses excluding persons who died before the second measurement and the results remained the same with the exception of income inequalities in men s mortality inclusion of men with shorter term survival and income in retirement thus tends to slightly underestimate the income inequalities as well as the potential of their explanation by accounting for change another sensitivity analysis restricted only to respondents with complete data conveyed that exclusion of missing categories from the analysis provided similar results to those presented herein discussion this study revealed that addition of a second measurement for risk factors provided rather modest improvement in explaining educational and income inequalities in mortality in men and women behavioral factors proved to be the most important group of factors in explaining educational inequalities in mortality in men and women with largest increase in explained share when measured over time psychosocial factors were most important in explaining income inequalities in mortality in men with very small increase in explanatory share over time on the contrary known biomedical factors together with employment status had more predicative power at the baseline compared to measurement over time these differences in explained share between different groups of factors over time can be attributed to different development in social patterning of explanatory risk factors over time previous research indicates that behavioural factors are among the most important in explaining mortality inequalities 1830 and our findings support these conclusions in particular our results underscore the importance of behavioural factors for low educated women s mortality a comparison with results from british 19 dutch 35 and french 20 based studies indicates that the effect size of behaviours in explaining mortality inequalities in norway is between british and french populations and somewhat comparable to dutch respondents our results also highlight the impact of these factors due to increased social patterning over time the largest increment in explaining excess mortality due to behavioural change was observed in women with lowest versus highest income despite having an egalitarian welfare state 31 norway s health promoting messages might have had a larger impact on information uptake and change in unhealthy behaviours in the most affluent groups 32 nevertheless the size of explained share in mortality due to change in behaviour was rather modest in the current inquiry compared to the whitehall study 18 we suggest that these differences between the studies may be ascribed to differences in the populations studied differences in measurements 33 and to differences in culture and social patterning of risk factors 2033 our findings also underscore the importance of psychosocial factors in health inequalities comparable in size to other traditional risk factors such as smoking and overweight 3435 for men psychosocial factors were much more important for explained share in income and educational inequalities in mortality than for women this finding is in line with previous evidence that the mortality gap between married and unmarried is higher for men 1422 adverse psychosocial factors in men might be associated with larger exposure to stress and more risky and unhealthy lifestyles 3637 and especially in men with low income since they are more prone to partake in smoking and other risky behaviours as compared to higher income men to examine this explanation in our data we calculated the combined explanatory share of psychosocial and behavioural factors at baseline resulting in odds ratio for the lowest income quartile explaining 52 of the excess mortality the indirect effect of psychosocial factors on men s mortality through behavioural factors was thus 8 the effect size of psychosocial factors in men s mortality is comparable to other studies doi101371journalpone0124690t005 were not gender stratified 32138 however change in psychosocial factors did not much amend the explanation of mortalities inequalitiesmost likely due to decrease in social patterning of psychosocial factors over time a usbased study showed slightly larger explanatory power of change in psychosocial measures in explaining social inequalities in mortality compared to the present study 21 and such difference might be attributed to differences in included risk factors note standardized by the direct method all changes in prevalence differences were statistically significant doi101371journalpone0124690t006 biomedical factors and employment status explained rather little in mens inequalities but performed better in women at baseline however when entered as timevarying variables the explained part was smaller than at baseline for both sexes our findings correspond with previous research where repeated measurements of biomedical risk factors improved the explanation of excess risk only to a very little extent 39 the observed pattern of better explanation by factors measured at baseline can to some extent reflect that biomedical risk factors had generally high prevalence at the baseline in all socioeconomic groups while differences in prevalence between socioeconomic groups remained the same or reduced this indicates that in spite of large increase in prevalence of these risk factors in the sample their minimal social patterning over time did not improve the explanation of inequalities this is in line with previous findings of decrease in educational disparities in obesity in the us due to increase in obesity prevalence in all educational groups over time 40 in addition socioeconomic inequalities diminish in older populations most likely due to early death of least healthy individuals 4142 and fadeout of biological risk factors in older populations 43 since biomedical factors might be the most proximal indicators of physical conditions preceding serious illnessdeath it is also reasonable to expect that these factors can explain mortality better in short term survival than new measurements in people who have survived until followup similarly employment status measured earlier in life has perhaps more important bearings for mortality than its change measured 10 years later in addition there was an enormous decrease in differences in homemaker employment status between high and low educated women over a 10 years period in this paper we focused on explaining relative inequalities in mortality and our rather limited set of biomedical factors seemed to contribute very little to the explanation however on the population level decrease in prevalence of biomedical risks would perhaps result in strong reduction of population health burden in absolute terms 44 the employed risk factors utilising a single time measurement explained a smaller share of educational inequalities in men s mortality compared to our previous work utilising the hunt 2 study 4 this difference might partly be attributed to different design and a to larger number of explanatory factors employed in the study utilising the mid 90 s data although the current study s results from the mid 80 s are not directly comparable to the results one decade later they might also reflect the fact of increasing relative educational inequalities in mortality in norwegian men and women over time 45 as well as a stronger social patterning of lifestyle risk factors such as smoking 10 explanatory factors of mortality inequalities might operate differently in younger as compared to older populations due to differences in social stratification social distribution of risk factors or health selection 38 we found that education and income inequalities in mortality were generally smaller in older people our finding of larger explanation of health inequalities by baseline factors in younger population compared to older people is in line with prior research 11 this pattern can perhaps be ascribed to larger mortality inequalities and more pronounced differences in risk factors related to premature mortality 14 we also found that the explained share by change in psychosocial and behavioural factors and the decrease in explanatory share by change in biomedical factors and employment were larger in the older population as compared to the younger this finding can be attributed to higher or lower explanatory power of different risk factors of survivors in an older subpopulation with relatively high mortality rates and successively decreasing mortality inequalities compared to the younger subsample nevertheless research on cumulative risk in elderly population is still very limited 1146 as most previous studies focused on middleaged 820 strengths and limitations this study has several advantages such as examining a large population over several points in time and being the first study to report mortality results separately for men and women in order to gain a better perspective on gender differentials however it is not without limitations a shortcoming to this study is that we included a wide range of factors however some factors which have been found to play an important role in explanation of health inequalities in other studies were beyond measurement possibilities of the current study inclusion of other factors or more repeated measurements could potentially provide a slightly different picture 47 measurement error introduced by selection of variables and measurement accuracy of those variables together with omitting any potential confounding factors for the exposureoutcome association and explanatory factoroutcome association might have resulted in inaccurate estimation 48 our analysis was based on the assumption of causal relations between explanatory risk factors and mortality and no interaction by the explanatory factors 48 we acknowledge that mediation analysis accounting for exposuremediation interaction and assessing direct and indirect effects might provide more accurate estimates 48 in addition our statistical approach could not account for possible confounding of the direct effect of ses on mortality 49 it is also known that explanatory factors are interrelated to each other and can work as mediators 34 as confounders 48 or interact with each other the latter possibly resulting in increased explanatory share 5051 in order to simplify presentation of the results we calculated odds ratios only for each set of risk factors separately although the possible pathways and relations between different groups of risk factors are much more complex and mutual influences cannot be precludedie the effect of behavioural risk factors might be mediated via psychosocial factors and vice versa the division of risk factors into groups was based on previous research 4 however some risk factors could arguably be assigned to another group of risk factors moreover income can also be viewed as an important material factor through which education might influence mortality furthermore since social patterning of health risk factors may vary between countries studies of other populations might reach different conclusions conclusions this study revealed that inclusion of repeated measurement of risk factors had only modest effect on explaining educational and income inequalities in mortality in norwegian men and women our results highlight the significance of behavioural factors and their socially conditioned patterning in both men and womenin particular between low and high educated womenwith a growing divide in relation to mortality findings thus call attention to the importance of health policy measures to alter behavioural paths in socioeconomically disadvantaged groups in order to tackle the growing health gap our finding of the relative importance of psychosocial factors in men s mortality but with its comparatively small increase in explanation over time suggests that the setup of mens psychosocial factors related to low socioeconomic position represents a considerable risk in respect to mortality remaining approximately constant over a 10 year period this implicates that measures to prevent such risks are best to be implemented early in the life course of men before reaching a conclusion whether timing of measurement can influence how well different pathways explain socioeconomic inequality in health more comparative research is required nevertheless we underscore that although measurement of timevarying risk might increase explained share of health inequalities other factors such as employment or biomedical risk might provide more explanation when assessed at baseline

socioeconomic inequalities in mortality can be explained by different groups of risk factors however little is known whether repeated measurement of risk factors can provide better explanation of socioeconomic inequalities in health our study examines the extent to which relative educational and income inequalities in mortality might be explained by explanatory risk factors behavioral psychosocial biomedical risk factors and employment measured at two points in time as compared to one measurement at baselinefrom the norwegian total county populationbased hunt study years 1984study years 86 and 1995study years 1997 respectively respectively 61 513 men and women aged 2580 825 of all enrolled were followedup for mortality in 25 years until 2009 employing a discrete time survival analysis socioeconomic inequalities in mortality were observed as compared to their highest socioeconomic counterparts the lowest educated men had an or odds ratio of 141 95 ci 129155 and for the lowest income quartile or 159 1481571 for women or 135 117155 and or 140 128152 respectively baseline explanatory variables attenuated the association between education and income with mortality by 54 and 54 in men respectively and by 69 and 18 in women after entering timevarying variables this attainment increased to 63 and 59 in men respectively and to 25 income in women with no improvement in regard to education in women change in biomedical factors and employment did not amend the explanationaddition of a second measurement for risk factors provided only a modest improvement in explaining educational and income inequalities in mortality in norwegian men and women accounting for change in behavior provided the largest improvement in explained inequalities in mortality for both men and women as compared to measurement at baseline psychosocial factors explained the largest share of income inequalities in mortality for men but

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f ollowing the 1996 welfare reform in the united states american social policy research largely concluded that single mothers can be pushed to work for example by claiming that the increased employment of single mothers has been achieved to a much greater degree than anyone expected moffitt affirmed classic arguments about how generous social policies have adverse labor supply effects this conclusion also affirmed the intuition that single mothers would be especially responsive to cuts in benefits utilitymaximizing single mothers the argument goes could find parenting to be more meaningful and rewarding than lowwage work while generous welfare programs subsidize the decision not to work conversely the inescapable costs of raising children could be a particularly strong incentive to work in the absence of generous welfare programs consistent with this line of thinking the reduction in welfare generosity in the united states did coincide with a substantial increase in single mother employment despite the prominence of this american literature its conclusions have been subjected to little crossnational scrutiny indeed the american literature rarely acknowledges that the us case is unusual in terms of high inequality weak social policies and lack of institutions supporting working mothers compared to other rich democracies the risk of poverty and unemployment for single mothers is also unusually high in the united states the usbased literature has nonetheless been quite influential for economic and social policy debates since the 1990s albeit less punitive than the us reforms the working families tax credit introduced in the uk in 1999 similarly aimed to increase employment of single mothers the uk subsequently documented rising employment rates among single mothers and doubled down on restricting lone parents entitlements to social assistance in 2008 by contrast though a reform similar to the personal responsibility and work opportunity reconciliation act in the netherlands in 1996 did not increase single mother employment is the us case unusual if indeed the american findings are not robust across countries this should qualify the general conclusions drawn from the us case rather than a general relationship between welfare generosity and single lena hipp is the head of the research group work care at the wzb berlin social science center and holds a professorship at the university of potsdamgermany her research on social inequalities related to gender and family has been published in various journals including european sociological review journal of marriage and the family social forces and socioeconomic review note previous versions of this article were presented at the european social policy association network american sociological association and swiss sociological association meetings we thank those audiences the editors of this volume an anonymous reviewer as well as the reading group at the lse social policy department for their suggestions and comments mother employment the observed relationship may be idiosyncratically dependent upon the contingencies of the united states moreover a robust comparative literature would enable the united states to learn from other rich democracies both in terms of the limitations of welfare disincentives and how institutions and social policies can support single mothers this study provides unique crossnational scrutiny by investigating two research questions first do generous welfare benefits discourage single mother employment generally across countries second if not how does the relationship between welfare generosity and single mother employment vary crossnationally we combine individuallevel data from the european union labour force survey for europe and the us current population survey from 1992 to 2015 in one of the largest samples of single mothers ever assembled we analyze nearly 600000 single mothers in up to 363 countryyears across twentythree countries we assess single mothers employment and work hours and model welfare generosity by constructing a unique indicator that captures minimum income protection for single mothers specifically using twoway fixed effects models our analyses yield three key contributions first we demonstrate that welfare generosity does not generally undermine single mother employment across countries second we describe the extent of crossnational variation in the relationship between welfare generosity in single mother employment and third we compare the prominent us case against other rich democracies to contextualize the limitations of the usbased findings we argue that no generalizations should be drawn from single country studies especially when based on the us case and that research should pay close attention to the pervasive and salient interactions between institutional contexts and social policies the case for crossnational comparison and variation there are at least four reasons for meaningful crossnational variation in the relationship between welfare generosity and single mother employment first a universal theory of welfare as a disincentive to employment has been undermined by a growing comparative literature that uses natural experiments and randomized controlled trials for example welfare reforms in the netherlands that reduced benefit levels for single parents resulted in little change in employment these studies encourage skepticism about research that relies disproportionately on formal models simulations and single countries like the united states second descriptive crossnational patterns in welfare generosity and single mother employment contradict the purported relationship while countrylevel crosssectional patterns cannot identify causal relationships they provide prima facie evidence that generous welfare states do not necessarily lower the employment of single mothers for example in a crossnational study destro and brady find that single mother employment is actually highest in more generous welfare states and lowest in weaker welfare states crossnational findings thus suggest that even if there might be welfarerelated disincentives to work within countries there must be countervailing forces that mitigate any possible negative effects of welfare generosity on single mother employment third some social policies have been shown to actually facilitate single mother employment in contrast to the american literature european social policy scholars focus less on welfare disincentives and more on the employmentenhancing effects of workfamily and other social policies as well as policy design for instance misra and colleagues show that public childcare and paid family leave encourage single mothers to stay in employment for the united states studies show the california paid leave program boosted mothers employment this is partly because public childcare reduces the costs of employment and effectively subsidizes employers moreover paid leave increases the likelihood of mothers staying at their jobs partly because generous welfare programs improve the health and wellbeing of single mothers related to this tax credits function as employer subsidies that boost employment evidence from the uk suggests that working family tax credits increased single mother employment in the united states the earned income tax credit was particularly effective at raising single mother employment in the 1990s likewise countries like france and germany have introduced earnings disregards for people on social assistance that allow them to retain their full benefit if they earn some extra income closely related is the general trend towards more conditionality monitoring and sanctioning associated with the receipt of welfare benefits which may have also facilitated employment in the netherlands and some of the nordic countries for instance social assistance recipients are made to sign integration contracts and need to actively look for work and accept job offers in order to receive benefits hence the aforementioned push of cuts to welfare benefits may actually be due to the pull of policies incentivizing work since generous welfare states are complex and interdependent combinations of more extensive workfamily policies and higher benefit levels countries with more generous welfare benefits may have higher single mother employment fourth any social policy is unlikely to have the same causal effect across contexts given the focus on internal validity and causal identification in social policy research external validity and causal generalization are often neglected however there is considerable evidence that social policies do not have the same effect across every institutional economic and cultural context social policies are always part of a complex of interdependent and intricately interacting institutions in turn a specific policy effect is effectively moderated by helping factors in the underlying institutional context for example the availability of affordable housing active labor market policies or minimum wage regulations therefore we cannot be certain how much of the effect is actually and solely due to the policy as opposed to the implicit interaction between the policy and context since there are strong reasons to suspect that results from the highly unusual us case might not generalize to other rich democracies it is essential to remain cautious in drawing general conclusions for all of these reasons the relationship between welfare generosity and single mother employment warrants crossnational scrutiny in the following we present a crossnationally comparative study to assess how the relationship between generous welfare benefits and single mothers employment and work hours varies across different economies by this we demonstrate generous benefits do not necessarily disincentivize labor market participation lessons from us studies in that spirit should not be taken at face value and applied to other contexts rather the united states can be seen to be an outlier and economies that embed generous benefits in alternative contexts can still achieve high employment among single mothers data and methods sources sample and variables we harmonize crosssectional individuallevel data from the eu lfs and the cps for the years 1992 to 2015 we then pool this merged individuallevel dataset with macrolevel indicators from several different sources even though some countries entered the eu lfs later the necessary information to identify single mothers is not available for all countryyears and we lack macrolevel information for some countryyears our analyses incorporate almost 600000 single mothers in up to 363 countryyears across twentythree countries 1 we identify single mothers as all female household reference persons who live without a partner in the same household but with at least one child below the age of 15 to limit bias that may occur due to differences in education and retirement across countries we restrict the sample to mothers aged 25 to 54 2 figure 1 shows that the ratio of single mothers to all mothers aged between 25 and 54 with children less than 15 years varies considerably between countries and over time while some countries have had a relatively stable and low proportion of single mothers in other countries the proportion of single mothers has grown over time or has constantly been on a high level figure 1 illustrates the us case is actually fairly unusual for having such stability at such a high level we analyze two outcomes following the international labor organization definition single mothers employment status is coded 1 for employed single mothers who work at least one hour per week and 0 for those single mothers who do not among the jobless we do not distinguish between unemployment and inactivity to avoid the issue that generous benefits might lead jobseeking individuals to withdraw from the labor force our second dependent variable is single mothers working hours volume which further assesses the extent to which individuals are economically active this variable captures single mothers working hours in all jobs in the reference week in order to make crosscountry comparison possible we assign a value of 0 to those who currently do not pursue paid employment our main explanatory variable is welfare generosity for single mothers using data from nelson and colleagues our measure concentrates on minimum income protection for single parent households the main component of this measure is social assistance payments housing supplements child support and other benefits are added as long as they are not deducted from social assistance to be able to compare generosity across countries we take a relative perspective on generosity and use nelson and colleagues absolute numbers to construct the ratio of welfare payments to the average wage in the respective year and country the online appendix features two alternative measures to assess the robustness of our results data on public expenditure on social policies as a percentage of gross domestic product obtained from the oecds social expenditure database and scruggs jahn and kuittos welfare state generosity index these measures assess the generosity of welfare benefits in general and have been used widely in existing studies we include the following microlevel covariates to adjust for compositional differences and potential confounding age education the number of children aged 15 and younger living in the household a dummy indicating if at least one of the children is below the age of 5 a dummy indicating whether there is an additional workingage individual present in the household who might take on care responsibilities or provide additional income and a dummy variable indicating whether there is an older person in the household who might either help with or add to the care responsibilities we adjust for the following macrolevel indicators to rule out alternative explanations for variation in single mothers labor force involvement across countries and over time and that are correlated with welfare generosity active labor market policies as a percentage of gdp 3 and public expenditure on early childcare and early education as a percentage of gdp to control for the business cycle we the annals of the american academy also include mens unemployment rate which we calculate based on our microlevel data from the eu lfs and the cps analytical strategy to assess the effect of welfare generosity on single mother employment and working hours we estimate twoway fixed effects models with robust standard errors clustered at the countrylevel the online appendix provides a technical description of the models 4 despite some debates on twoway fixed effects models the twoway fixedeffects coefficients can be interpreted as the average difference in withincountry deviations from the mean in the single mothers employment and work hours at a given time point for each oneunit withincountry increase in the respective benefit indicator at a given time point averaged across time points 5 for both dependent variables we proceed as follows we first estimate a model that includes the respective dependent variable minimum income protection and the country and year fixed effects next we introduce the microlevel covariates the third model introduces the macrolevel covariates the final model introduces interactions between benefit indicator and country dummies this enables us to compute countryspecific associations between benefit levels and the outcomes the estimated coefficients are based solely on variation within the specific country and thus will be less robust for countries with shorter time series however without delivering causal estimates of the policy effect for each country the approach clearly illustrates the variation in the relationship of interest we display this sequence rather than only the full models because we want to compare the coefficients for the benefit indicators as well as the countryspecific coefficients across different specifications some of our covariates especially the macrolevel policies could be affected by benefits and including them could lead to overcontrol bias showing coefficients across these models clarifies how large of a problem this might pose all analyses use standardized oneyear lagged measures for all countrylevel variables standardization facilitates the interpretation and comparison of coefficients in multivariate analyses lagging partially addresses issues of reverse causality and recognizes that policy changes tend to have a delayed effect 6 results descriptive patterns we first present employment rates and average working hours of single mothers partnered mothers and single childless women aged between 25 and 54 years to provide some comparison and context for how womens employment varies crossnationally and over time in most countries single mothers employment rates have been rising since the early 1990s as have employment rates of partnered mothers and all workingage women notable exceptions are austria and germany where single mother employment remained stable or declined relative to the comparison groups albeit from a comparatively high starting level several countries also show a decline in employment around the time of the 2008 economic crisis in several countries for example spain ireland and the slovak republic single mothers were particularly affected by labor market developments during the crisis consistent with the welfare reform literature the united states did see a significant increase in single mother employment in the 1990s however that increase began as early as 1992 several years before the 1996 welfare reforms further most countries saw an increase in single mother employment regardless of any welfare reforms the united states was not unusual for seeing an increase in single mother employment hence it did not require usstyle welfare reforms to experience rising single mother employment in this longerterm period the more notable quality of the united states is that since 1999 single mother employment has been stable at a high level or even modestly declined from a high level this has happened despite any change in welfare generosity because the dichotomous variable employment neglects variation in the extent to which individuals pursue paid work we next display the average work hours of single mothers partnered mothers and single childless women in figure 3 nonworking women are coded as working zero hours in order to establish comparability across countries over time and across the different groups of women while there is less variation in single mothers working hours over time than in their employment rates the crossnational variation is still considerable in the uk the average working hour volume has been about 15 hours per week in the united states it was about 35 hours per week again we see the unusualness of the us case as single mothers average hours worked is both high and stable in the majority of countries and years single childless women tend to work longer hours on average and partnered mothers work shorter hours than single mothers in france latvia the netherlands poland portugal and sweden single mothers work hours have been approximately the same as that of partnered mothers on average only in denmark ireland and in the early 2000s in slovenia have single mothers worked fewer hours than partnered mothers to display the degree to which single mothers employment rates and work hours correlate with countries welfare generosity we inspect bivariate associations in figure 4 figure 4 plots the differences between the first and last year for each country for single mothers employment rates and working hour volumes against the change in minimum income protection over the same period this difference between first and last year mimics the overtime changes analyzed in the subsequent models figure 4 shows no association between overtime changes in single mothers employment rate or work hours and changes in minimum income protection twoway fixed effects models we now turn to the twoway fixed effects modelsfigure 5 shows the marginal effects of our welfare generosity measure on employment and work hours of single mothers m1 is based on the model that only includes the lagged minimum income protection indicator and country and year fixed effects the coefficients for minimum income protection reveal a negative but statistically nonsignificant association with both single mother employment and working hours the association is statistically significant in m2 which includes microlevel covariates here a standard deviation increase in minimum income protection is associated with a 2percentagepoint decrease in the probability to be employed and a 06 hour decrease in working hours respectively this negative effect is small by any reasonable standard more importantly the association is 0 between minimum income protection and employment or work hours in m3 which also includes macrolevel covariates thus in our analysis the association between welfare generosity for single mothers and their employment outcomes is basically zero when adjusting for potential confounders to examine the degree to which the association between welfare benefits and single mothers employment varies across countries we interact our benefit measure with the country dummies included in our regressions the results of these analyses are graphically displayed in figure 6 the marginal effects of minimum income protection on single mother employment vary considerably from around 7 or 8 percentage points per standard deviation to around 14 percentage points or 5 percentage points the marginal effects on weekly work hours vary from 3 hours to 5 hours or 4 hours there are indeed some countries in which the association between welfare benefits and single mothers employment outcomes is consistently negative additionally in some countries there is a negative association with one of the two outcomes in many countries however the associations are zeroor close to zeroandor statistically insignificant the united states is negatively signed but the coefficients are not statistically significant moreover there are some countries that show positive associations the us case is still unusual as only italy and the netherlands have a larger negatively signed point estimate given the variance in the associations it seems inappropriate to conclude welfare disincentives are powerful and crossnationally robust in sum and in line with the findings from the main effect models we find wide variation across countries in the association between benefits and single mothers employment outcomes strikingly two of the countries that are well known for their attempts to increase single parent employment through welfare reform and increasing incentives that is the uk and united states show positive or no association conclusion because of the influence of evidence from usbased studies since the 1990s there has been a general expectation that generous welfare benefits undermine further in most countries single mothers have higher employment rates than women in general in turn we systematically examine the relationship between welfare generosity and single mothers employment rates and work hours across countries and over time we used data on twentytwo european countries and the united states to construct an indicator of minimum income protection for single parents to model the relationship between welfare generosity and both single mother employment and work hours neither our descriptive nor our twoway fixed effects analyses showed an association between minimum income protection and single mother employment and work hours when assessing countryspecific associations we found that some countries show negative some positive but most countries show no associations for both single mother employment and work hours these findings undermine the prominent argument that cutting benefits will lead to higher employment among single mothers understanding the specific situation of single mothers employment poverty and wellbeing calls for understanding the complex interactions between various social policies and institutions rather than viewing reduced welfare benefits as a generic effective policy tool to incentivize single mother employment we conjecture that single mother employment is shaped by a constellation of policies and institutions combining a stable safety net with workactivating and familysupportive policies that foster employment for single mothers is most likely to encourage both employment and economic wellbeing for instance generous benefit levels are potentially more harmful to work effort in countries with comparatively low wage floors minimum wages set wage floors and thus the potential minimum rewards to work other institutions such as union strength and collective bargaining coverage may matter even more in this context our analysis has limitations first because our sample spans only twentythree countries we are limited in the number of macrolevel covariates which leaves us vulnerable to omitted variable bias second some might argue that generous benefits create incentives for single motherhood if true endogenous sample selection might bias our estimates third we do not address actual job quality aside from work hours thus we cannot make claims about whether single mothers obtain jobs that enable them to escape poverty or low wages finally the question of why there is so much variation in the association between benefits and single mothers employment outcomes is beyond the scope of this study promising avenues could be to analyze the availability of public childcare or to investigate the availability of quality labor market opportunities as potential moderators of the relationship overall our analysis makes three major contributions first we show welfare generosity does not generally undermine single mother employment across countries second we demonstrate substantial crossnational variation in the relationship between welfare generosity and single mother employment third we the annals of the american academy qualify how the us case is unusual relative to most countries as a result we urge greater caution and modesty about what can be learned from the us case or any single country instead other contexts might offer lessons to us policymakers the variation across countries demonstrates that high single mother employment is possible while maintaining generous social policies rich democracies provide a variety of mixtures of policies and institutions that reveal blunt welfare disincentives are not likely to generate high single mother employment thus rather than exporting the policy lesson that the 1996 welfare reform proved how single mothers can be pushed to work we encourage understanding of how social policies interact with other policies and institutions we ultimately encourage the social policy research community to value highlight and learn more from institutional variation rather than simple generalities about disincentives notes 1 the countries and years include austria 1992austria 2015belgium 1992belgium 2015czech republic 19972015germany 1992germany 2015denmark 2010denmark 2015estonia 1998estonia 2015finland 2003finland 2015france 1992france 2015hungary 20002015ireland 1992ireland 2015italy 1992italy 2015lithuania 2002lithuania 2015luxembourg 1992luxembourg 2015latvia 2001latvia 2015netherlands 1992netherlands 2015poland 20012015portugal 19922015spain 1992spain 2015sweden 2009sweden 2015slovenia 1996slovenia 2015slovakia 1998slovakia 2015united kingdom 19922015united states 19922015 for missing data at the individual level we assume missingness at random and use listwise deletion 2 robustness checks using alternative age ranges do not substantially differ 3 we use a measure that summarizes all types of almp expenditure except spending on administration 4 we run linear regression models we compare our coefficients with average marginal effects from logistic regressions for employment and poisson regression for work hours there are only slight differences that do not affect our conclusions 5 we crosscheck our models with coefficients from models that only include country fixed effects and find no differences that would affect our conclusions 6 robustness checks using contemporaneous macrovariables differ little from the lagged models supplemental material supplemental material for this article is available online

reform of the us welfare system in 1996 spurred claims that cuts to welfare programs effectively incentivized single mothers to find employment it is difficult to assess the veracity of those claims however absent evidence of how the relationship between welfare benefits and single mother employment generalizes across countries this study combines data from the european union labour force survey and the us current population survey 1992survey 2015 into one of the largest samples of single mothers ever testing the relationships between welfare generosity and single mothers employment and work hours we find no consistent evidence of a negative relationship between welfare generosity and single mother employment outcomes rather we find tremendous crossnational heterogeneity which does not clearly correspond to wellknown institutional variations our findings demonstrate the limitations of single country studies and the pervasive salient interactions between institutional contexts and social policies

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introduction this article explores the status of multiculturalism in contemporary europe focusing on four european union countries we investigate the ways in which their diverging responses to multiculturalism have informed a renaissance in thinking about how best to reconcile political unity with ethnic and religious difference one means through which this has proceeded has been cultivation and entrenchment of civic integrationist approaches what goodman describes as a set of civic hardware including integration contracts classes tests and ceremonies we are especially interested in the extent to which this civic hardware is deemed to redress multiculturalisms alleged shortcomings not least because a number of authors have stressed a relationship between a civic turn and a retreat from multiculturalism for example joppke amongst others has insisted that civic integrationist approaches are most visible in britain and the netherlands the two societies in europethat had so far been most committed to official multiculturalism one cautionary response to this reading is that joppkes interpretation assumes a dichotomy between civic integration and multiculturalism or at least places the two in a zerosum equation that ignores the extent to which they could just as plausibly be synthesized in a potential outgrowth of one another 5 it is important to stress however that while we pay particular note to the elevation and promotion of civic integrationist measures we approach these by situating them in a politicisation of public policies on integration and citizenship thus we are not here offering a systematic comparison of civic integration measures for this would repeat a collection of work that can be found elsewhere puts this differently but makes a similar point in her observation that a state can widen or liberalise the scope of people who are eligible to apply for citizenship while raising the expectations for new citizens in other words increasing the obligations of citizenship does not necessarily cancel out historically established or recently won membership rights and weil 2001 6 we instead want to provide a contextually sensitive account of the fate of multiculturalism by returning to recent policy developments where we can observe a cluster of seemingly novel tendencies and yet which illustrate how the salience of recent civic integrationism only really makes sense in relation to debates about multiculturalism we use the term novel to register a shift onto the identity of membership itself in a manner that has sought to give particular content to that membership in both vertical individualstate relations as well as horizontally across civil society and social groups according to kostakopoulou this is present across europe in policies for social cohesion integration and assimilation including the official promotion of national identity official lists of national values language and clothing prohibitions in public transport schools universities and hospitals compulsory language courses and tests for migrants naturalisation ceremonies and oaths of loyalty several elements of this description are recognisable in both britain and the netherlands two of our chosen countries which though differing from one another in their approaches to the integration of ethnic minorities have previously rejected the coerciveassimilationist or ius sanguinisexclusive approaches of other continental examples yet here too the instrumentalisation of citizenship for minority integration which emphasises the symbolic value of citizenship as an identity status has increasingly been pursued as a short term panacea to the sorts of societal disunity allegedly associated with ethnic minority separatism in general and muslim alienation estrangement and violent extremism in particular no less striking perhaps even perplexing is that countries which have historically either actively rejected or benignly ignored multiculturalist public policies and so have never adopted them such as germany and denmark claim that such policies have failed in their countries too for example the german chancellor angela merkel declared in october 2010 that multiculturalism has failed completely failed in germany while søren pind the former danish minister of integration insisted on the need to reassert that the right word must be assimilation there are so many cultures and people can go elsewhere and engage with them if this is what they want four cases or two pairs these four cases the netherlands uk germany and denmark are presented as two pairs that will facilitate a distinct inquiry because each pair has either incorporated or rejected multiculturalist policies but has done so in different ways that cannot be understood without grasping something of their national policy trajectory for example banting and kymlickas multiculturalism policy index which monitors multicultural public policies across twenty one western democracies across three intervals tells us that in 2000 the netherlands and britain scored 55 and 55 out of a possible 8 respectively and denmark and germany scored 05 and 2 respectively by 2010 the score for the netherlands had been reduced to 2 britain remained the same denmark was at 0 and germany had increased to 25 this offers a mixed picture of the fate of multiculturalism that is given qualitative support in vertovec and wessendorfs reading that while the term multiculturalism has disappeared from the political rhetoric this is something that is not paralleled by the eradication nor much to the detriment of actual measures institutions and frameworks of minority cultural recognition while the criteria banting and kymlicka use goes beyond antidiscrimination to offer some degree of positive recognition accommodation and support of minorities taken on its own the index risks overlooking the richer contextual explanation that can be garnered from an excavation of recent historical policy developments these are especially relevant to the why questions amongst them why have states with different migration and integration policy experiences adopted civic integration policies to our minds however this question rests on a prior investigation of what is expressed in the debates that these four countries with such different experiences have come to have over multiculturalism these are necessarily empirical as well as theoretical questions that relate to timing and context in the process of policy change to which we turn next our broader point is not to deny either the structural reasons for the development of post multicultural agendas nor that changes do not also reflect power political and discursive shifts an objective instead is to show how arguments regarding multiculturalisms retreat in europe do not do justice to the complexity of the processes that led up to the adoption of civic integrationist policies in the netherlands britain germany and denmark something that obscures the ways in which multiculturalism can be seen to wear different faces drawing on data compiled in the crossnational civiturn project we rely on policy documents governmental statements and public discourse that formed part of a five workpackage analyses the materials were selected and coded by each national partner and a conventional inductive analysis was undertaken before the data were brought together qualitatively and synthesised by the research team it is therefore worth restating that we are not undertaking a systematic review type comparison on civic integration measures but instead seek to grasp the nature and process of change in no less rigourous fashion but focusing on the motivations and form of policy change broadly conceived and it is to this that we next turn modeling policy change it is widely accepted that attempting to understand policy change can be a dense and at times elaborate activity and to the extent that there is a prevailing account of what the study of policy change should incorporate it could be argued that this seeks to explore a series of distinct but interrelated stages the precise configuration and description of stages reflects the wider theoretical stance that is adopted but these stages can typically comprise problem identification agendasetting consideration of potential actions implementation of agreed action and evaluation in their account banting and kymlicka point to two expressions of institutionalist thought the first is inspired by biological models of evolutionary development especially baumgartner and jones notion of punctuated equilibriums which posits that systems can quickly shift from one period of relative stability to another they argue these punctuations occur when persuasive ideas gain increasing attention a situation which depends on external factors as well the inherent qualities of an idea as banting and kymlicka note many interpretations of the shift from multiculturalism to civic integration have this flavour the second expression they characterize as incremental adaptation which implies that change takes place even in the context of stability in formal programs through processes of drift conversion and layering this latter point is especially important for both banting and kymlicka as well as to us for it maintains that our understanding of changes needs to assume that each new generation does not start with a black slate understanding the evolution of immigrant integration according to this perspective requires the mindset of an archeologist we take seriously the observation of incremental adaptation by seeking seek to offer a policy genealogy in order to assess the implications and understand the permutations of the backlash against multiculturalism to probe this we will focus upon four illustrative cases comprising two national contexts where different modes of multiculturalism have been embraced and two national contexts where it has never been adopted our argument is that the underlying dynamics already evident in these cases are essential in delineating the postmulticultural turn in europe for the following reasons whereas current accounts employ the narrative of a relatively seamless movement in the pendulum that has directed the momentum from being in favour to being against multicultural policies the momentum behind this pendulum must necessarily have been staggered in that each national context has a different starting point in this journey leading to a more complicated and mixed outcome hence while each of these four countries currently experience a civic integrationist turn the logic of the manner in which this turn is a reaction to a perceived crisis of multiculturalism the meaning of the post in postmulticultural as it were is quite different at the level of discourse as well as policy change in the next section the article will offer a detailed account of the inception and then movement away from positions in favour of multiculturalism in two countries that have adopted different versions of it namely the uk and the netherlands and the emergence of strong civic cultural criticisms of the crisis of multiculturalism in two countries that never had much multiculturalism in the first place but were also late in perceiving the need to integrate its newcomers at all namely denmark and germany the netherlands and britain a backlash in multicultural states given the often assumed similarity of dutch and british postcolonial multiculturalism the challenge to of previous minority accommodation policies in the netherlands has struck observers as both remarkable and indicative of the shape of things to come elsewhere yet we need to grasp how in both cases different starting points herald implications for the maturity of different reactions by this we refer to the longevity or the extent to which multicultural policies have been embedded and sedimented in political cultures and public policies in our cases including in more discursive notions of belonging which may either mitigate or accelerate the ease with which multiculturalism may be dislodged this is related to our further argument which concerns the assumption of an alleged homogeneity in the provenance of these developments principally attributing them to millennial anxieties over ethnic minority separatism in general and muslim alienation estrangement in particular drilling down into the dutch and british cases first and the german and danish cases next shows that this provenance is in fact quite mixed not only were some countries more multiculturalist to begin with and others hardly at all none were cut from the same cloth hence the netherlands was never an archtypical multicultural country and its internal critique of multiculturalism occurred relatively early and indeed not long after it had been embraced dutch multiculturalism began as a peculiar mixture of welfare statist laissezfaire gastarbeiter returnism and continuation of the countrys legacy of ideologicalreligious institutional segregation socalled pillarisation this tradition extended well into the 1950s and 1960s when many facets of everyday social life in the netherlands were organised according to very distinct protestant catholic socialist and liberal constituencies albeit with an overarching ethnonational and political dutch national identity with the postwar movement of 300000 migrants from former colonies as well as the arrival during the 1950s and 1960s of guest workers from southern europe yugoslavia turkey and morocco the social structure of pillars for existing minorities was simply extended to incorporate ethnic minorities as well the extension of this mode of social organisation to migrants was at first anticipated to facilitate their return home 7 with the key premise that policies aimed at permanent integration could hamper such returning it was only later that the retention of cultural identity was seen by segments of the political left in particular as a vehicle for emancipation and integration in dutch society and that cultural diversity was considered a means of enriching society yet unlike britain or canada few attempts were made at least at the national level to either change the majority societys institutions to incorporate this new religiouscultural difference in dutch national identity and official public culture the first official immigrant integration policy in the netherlands was not therefore developed until the early 1980s with a draft minorities memorandum in 1981 and the final minorities memorandum in 1983 the new policy was based on the assumption that ethnic minorities would remain in the netherlands previously temporary guestworkers or colonial migrants they now were recognized as permanent cultural or ethnic minorities within dutch society policy discourse thus stressed the socialcultural emancipation of minorities political participation combating discrimination and enhancing the socialeconomic participation of members of minorities however the conceptualisation of cultural integration as retaining something of earlier identities which has been called multiculturalism avant la lettre was subject to criticism from the late 1980s when a report by the influential scientific council for government policy concluded that insufficient progress had been made in areas such as the labour market and education and that too much emphasis on retaining cultural identities was hindering ethnic minority participation in both indeed the same council that had advocated the multicultural integration of minorities in 1979 now advised the government to focus on the civic integration of allochtonen instead of minorities and to balance the rights of immigrants with obligations contrary to popular belief therefore a public commitment to an idea of multiculturalism was by no means certain even at this early stage two years later frits bolkestein had initiated a now familiar debate on the promotion of a leitkultur of western values the important feature of this debate was the extent to which it centred on an objection to islam and more precisely the role islamic culture allegedly played in hindering the integration of immigrants bolkesteins initiated a parliamentary debate on minorities in 1992 while his binary defence of our liberal culture against their islamic culture may not have been widely shared the alleged multicultural elements of ethnic minorities policy that he criticized tapped into a zeitgeist which maintained that the integration of immigrants had been limited and that something had to be done a new vision of integration was therefore emerging and by 1994 a ruling cabinet consisting of christian democrats and social democrats introduced the policy memorandum integration of ethnic minorities this emphasised at a very early stage compared to the rest of western europe good citizenship and selfresponsibility in a manner that promoted a shift away from disadvantaged groups towards individuals and from emphasizing cultural and multicultural policies towards socioeconomic incorporation policies the notion of citizenship that was achieving traction reflected a view that the duties of citizenship had too long been under emphasised and so in 1998 the purple cabinet introduced the civic integration act which obligated migrants to take language lessons and introductory courses on institutions and practices of society although civic integration courses were initially introduced as instruments to facilitate immigrants socioeconomic integration they would soon be transformed into requirements for obtaining residence permits and legal citizenship each of these developments was well underway long before 911 and other terrorist activity had contributed a security imperative to the revision of integration policies thus paul scheffers widely cited critique of multiculturalism in the netherlands the multicultural drama gave form to the view that the dutch had been too generous in accepting cultural difference while ignoring basic liberal democratic values and the importance of learning dutch language culture and history the article firmly oriented debates on the failure of dutch multicultural policies to the role of islam in the failure of the integration of muslim migrants before the fallout from 911 and domestic developments such as the electoral victory of the populist fortuyn party the murder of filmmaker and columnist theo that the dutch multiculturalism backlash was both early and a peculiar mixture of liberalism and modernist civic nationalism in part reflects the paucity of effective positive integration measures in such areas as education employment and housing and the fiscal vulnerability of a comprehensive welfare state to these failures but it also reflects the lack of multicultural civic integration understood as insertion of cultural and religious diversity and sensitivity to such diversity in the mainstream of an increasingly egalitarian and secularist society the pillarisation of islam informed the early development of a dutch version of germanys leitkultur concerns which was less conservative and more clearly antireligious than was the case in germany here incremental anxiety about the social and political segregation of muslims became coupled with an assertive liberalwayoflifedutchness which while deeply resonant with cosmopolitan elites was also advanced by right wing parties this way of life was associated with egalitarianism feminism autonomy secularism and traditions of tolerance but not since the early nineties and certainly not compared to britain with any a great appreciation of the value of diversity nor of the need for its burgerschap to make room for such diversity are there similarities here in the british case of course british multiculturalism is rooted in its specific historical background of imperial nationhood and a concept of citizenship that is to say that in the move from an imperial to a postimperial power britain approached the jus soli and jus sanguinis fork in the road but took a distinct path by implementing a peculiar synthesis of mainly jus soli with a doctrine of continuing allegiance to the crown accordingly those born as subject of the crown remained subjects regardless of emigration or even naturalisation for example the 1948 british nationality act granted freedom of movement to all formerly or presently dependent and now commonwealth territories by creating the status of citizenship of the united kingdom and colonies until they acquired one or other of the national citizenships in these postcolonial countries formerly british subjects continued to retain their british status this is one of the reasons why a common distinction between national minority rights and ethnocultural minority rights contained within anglophone social and political theory is not easily transposed on to britain from a national cultural perspective therefore beyond legal conceptions of citizenship rests on what asari haliliopoulou and mock consider the bitter irony of british multiculturalism since a ll of the civic assimilative signifiers upon which a multicultural british or for that matter english national identity could potentially draw from the existing historicalcultural matrix of myths and symbols are deeply implicated in the project of empire a political project that is not only past but conceptually discredited associated and not unjustly either with hierarchy and racism what this interpretation underemphasises is how migrant communities and british born generations have been recognised as ethnic and racial minorities requiring state support and differential treatment specifically in order to overcome obstacles in their exercise of citizenship and to prevent minimise and redress an impairment of their civic status so rather that assimilative and nationalcivic signifiers there developed a multicultural minority incorporation which had a civic intent in the sense of equal treatment understood as antidiscrimination removing of barriers to participation and antiracism this stresses a different type of civic incorporation from the civic assimilation in a historically tainted imperial nation of which the quote speaks this includes how under the remit of several racerelations acts the state has sought to integrate ethnic and racial minorities into the labour market and other key arenas of british society through an approach that has promoted equal access as an example of equality of opportunity indeed it is now nearly forty years since the introduction of a third racerelations act cemented a state sponsorship of race equality by consolidating and cumulatively building upon earlier weaker legislative instruments alongside its broad remit spanning public and private institutions recognition of indirect discrimination and the later imposition of a statutory public duty to promote good racerelations it also created the now defunct commission for racial equality to assist individual complainants and monitor the implementation of the act this is an example according to joppke of a citizenship that has amounted to a precarious balance between citizenship universalism and racial group particularism that stops short of giving special group rights to immigrants what it also suggests is that the creation of a space from which to begin to redress racially structured barriers to participation represents a defining characteristic in the british approach to integrating minorities yet the british case is not solely comprised of antidiscrimination for during the 1990s a specific form of multiculturalism emerged through developing certain racial equality discourses and policies beyond their starting points in a response to minority ethnic and religious assertiveness these rejected assimilationist perspectives and were inclusive of ethnoreligious minority groupings and took hold in a cumulative and progressive institutional form in for example the outlawing of religious discrimination and the incitement to religious hatred it also took educational form in the inclusion of some nonchristian nonjewish faith schools within the maintained sector in england in 1999 the stephen lawrence inquirys examination of police forces also introduced the concept of institutional racism shortly afterwards the commission on the future of multiethnic britain made policy recommendations to help a confident and vibrant multicultural society take advantage of its rich diversity so that britain should realise its full potential entitled the future of multiethnic britain their report strongly endorsed both the possibility and desirability of forging a metamembership of britishness under which diversity could be sustained its recommendations not only sought to prevent discrimination or overcome its effects they also advocated an approach that could move beyond conceptions of formal equality by recognising the substantive elements of real differences of experience background and perception it recommended that central government take steps in formally declaring britain a multicultural society hoping that such an approach would invalidate the social and political inequalities derived from minority cultural differences this document was criticized not only from the right but also by liberals who believed that its approach flouted universalistic principles not least those recommendations which promoted diversity as a means to facilitate equality moreover in the summer of 2001 after civil unrest and rioting in cities in the north of england multiculturalist policies became subject to further critique a local bradford report set the pattern by arguing that particular communities widely understood as muslim communities were selfsegregating this tendency was described in another report as part of a wider phenomenon of leading parallel lives after which a more integrationist discourse became prevalent in linking between community cohesion belonging citizenship and civicnational identity yet what largely goes unnoticed are the ways in which the rediscovery of citizenship discourses in the policy zeitgeist owes much less to anxieties about muslims in britain and much more to a reforming government in waitings commitment to civic renewal for example working closely with new labour and tony blair giddens drew on some of the core concerns of social capital theorists to propose his third way solution to an alleged civic decline in contrast to the old left which tended to be dismissive of worries about civic decline the new politics accepts that such anxieties are genuine civic decline is real and visible in many sectors of contemporary societies it is seen in the weakening sense of solidarity in some local communities and urban neighbourhoods high levels of crime and the breakup of marriages and families thus giddens saw the focus of a new labour administration as education incentives entrepreneurial culture flexibility devolution and the cultivation of social capital and it is significant how in his first speech as prime minister tony blair invoked the concept of social capital and some of the key concerns of theorists of social capital in maintaining that new labour would recreate the bonds of civic society and community indeed even while they were still in opposition the blair administration undertook a commission on social justice which reported that social capital was one means of addressing the civic deficit and material disadvantage of marginalized communities thus before and during taking office blair committed new labour to promoting civic activism as a complement to modern government … promoting better state and civic support for individuals and parents as they meet their responsibilities is a critical contemporary challenge cutting across our approach to education welfare and crime reduction what is therefore being argued is that the years immediately prior to and after labours general election victory in 1997 a range of key actors including politicians pundits academics thinktanks and pressure groups became increasingly concerned about a range of different problems of which civic integrationparticipation was only one but which closely corresponding to concerns of social capital theorists kisby has shown this pursuasively including how these perceived problems included concerns about a democratic deficit and low voter turnout and in particular about civic and political disengagement and cynicism among young people what needs to be stressed is that issues of muslim integration initially came to rest in this mould before that mould would be later recast thus when the term community cohesion enters the lexicon following an inquiry into civil unrest or rioting in some muslim areas in the north of england the commissioners conceive it as encompassing a domain of social capital which facilitates people to feel connected to their coresidents nevertheless by 2002 the nationality immigration and asylum act now explicitly in the test that applicants seeking british citizenship must sit requires a sufficient knowledge of english welsh or scottish gaelic and also a sufficient knowledge about life in the united kingdom immigrants seeking to settle in the uk also must pass the test if they do not have sufficient knowledge of english applicants have to attend english for speakers of other languages and citizenship classes in explanatory documents the home office stresses that the tests aim at integration but without this meaning complete assimilation what has been taking place in britain cannot therefore accurately be called a retreat of multiculturalism certainly it is true that the inclusion of ethnic minorities is now increasingly premised upon greater degrees of qualification however the british approach still promotes the mainstreaming of ethnic monitoring and positive duties of care critiques of the emergent multiculturalism of the 1990s continue to emphasise what is usually present in some form in most accounts of multiculturalism the question currently facing british multiculturalism concerns the extent to which the recognition of diversity needs to be offset with civic incorporation or more profoundly to what extent multiculturalism and citizenship can be mutually constitutive and defined in interdependent terms in a way that is inclusive of muslims germany and denmark the backlash in nonmulticultural states thus far we have discussed the sequence political provenance and permutation of counter multiculturalist movements in two states that had previously adopted favourable though very different approaches what however can be said of a retreat in countries which had never advanced multiculturalist public policies to explore this we can begin with germany a country that has until relatively recently displayed a long tradition of recruiting guest workers from neighbouring countries for example between the 1890s and the first world war during a period of rapid industrial growth it recruited large numbers of seasonal workers from poland and the austrohungarian and russian empires to address labour shortages during the weimar republic fewer numbers were recruited as a result of the great depression and rules that allowed foreign labour only if it could be shown that no german workers were available after the second world war three periods of recruitment may be distinguished firstly the arrival between 1945 and 1949 of nearly twelve million german refugees and expatriates secondly the importation of guest workers from turkey italy spain greece portugal yugoslavia and other mediterranean countries during the 1950s and 1960s to fill shortages of industrial labour and thirdly the three million ethnic germans who returned to germany following reunification despite this until the late 1990s german citizenship laws meant that in order to obtain german nationality applicants would need to prove german descent german citizenship was not automatically granted therefore to people born on german soil meaning that in the postwar period second and third generation immigrants remained outside its formal citizenry and so enjoyed fewer civil and political rights in the country of their birth than their nonminority peers as a consequence though germany does have constitutional protections politicians have not often faced electoral pressures to deal with issues of racism and accommodation of minority needs the important point is that until 1998 germany did not officially recognise the existence of migrants and ethnic diversity in society this political stance was adopted in 1973 by the official recruitment ban on foreign guest workers and the slogan germany is not an immigration country which reflected a political attitude but not the social reality germans have struggled to find acceptable ways to express collective pride and a shared sense of identity since the traumas of the second world war postwar west germany defined itself in contrast with nazi germany or an autocratic east germany often in european terms what positive definitions of national identity did emerge they tended to restrict themselves to a lowest common denominator the most distinctive of which was verfassungspatriotismus a concept introduced by sternberger and popularised by habermas amongst others this refers to the west german constitution of 1949 which was also adopted by the former east germans in 1990 this document builds on a longer german tradition of the rechtsstaat or rule of law the constitution is said to express positive ideals in which germans can take pride eg the inviolable dignity of human life and the duty of the state to provide the conditions for individual fulfilment it was only in the 1980s more than 25 years after the arrival of the first guest workers that a debate surrounding multiculturalism developed in germany since then german academics and politicians have controversially debated and developed the concept of multiculturalism some authors focused upon its ideological dimensions while others regarded multiculturalism as a threat demographic reasons for immigration were ignored in favour of the preservation of cultural and national homogeneity the catholic and protestant churches introduced the term multicultural society which is closely related to multiculturalism in 1980 during a day of the foreign fellow citizen with a view of broadening the publics view of this guest worker group instead of viewing the foreigners only in terms of their economic value and problems the german population should recognise the various foreign cultures which migrant workers had brought with them as an enrichment of german culture the subsequent debate over fairer terms of inclusion was driven by members of the green party as well as some more progressive figures within the conservative christian democrats however in the early 1990s some high profile episodes of racial violence prompted introspection on the assertion of german social tolerance it is around this period in 1993 that the term multiculturalism achieved a degree of salience and translations of the work of charles taylor featured in intellectual discussion habermas for example elaborated an idea of nationality that would no longer be linked to ethnicity but based on a continuing process of civilisation the cultural embedding of german democracy he argued should not be designed to cultureless besides or beyond the advanced welfare state of the postwar period this embryonic consideration of pluralism and diversity in public discourse was quickly challenged however in the leitkultur debates of the early 2000s indeed conservative christian democratic union politicians such as jörg schönbohm and friedrich merz had already begun to argue in 1999 in opposition to the then newly elected centreleft government of the social democrats and the green party that multiculturalism would encourage social conflict and undermine a common set of values despite this criticism the new schröder administration introduced new laws for immigration integration and citizenship that would address the concept of a volk as well as establishing an independent commission on immigration which in july 2000 recommended establishing clearer application criteria actively recruiting skilled migrants improving asylum procedures and implementing a comprehensive integration programme in reaction to the süssmuth commission in autumn 2000 friedrich merz then chair of the christian democratic union demanded that immigrants be willing to accept german mores which he termed liberal german leitkultur this initiated a series of contentious debates on leitkultur in the aftermath to 911 which seriously undermined efforts by the government to secure the level of political consensus required to introduce legislation based on the commissions recommendations for whereas previously the formulation of a german national identity was hampered by a nazi past or the communist east the leitkultur debate was oriented toward a new other namely immigrants especially turkishorigin muslims the debate over leitkultur was thus twinned with debates over the suitability of turkey for membership of the european union often employing very similar argumentation time suggested that almost half of the german population agree with sarrazins political views and 18 percent would vote for his party if he started one significant again is timing germany refusing its immigration country status well into the nineties while having a relatively benign experience of socioeconomic incorporation of immigrants only began to in earnest of integration around the millennium when it finally did discussion revolved around conditions of citizenship and naturalisation these conditions no longer ethnic were predominantly conceptualised in securitized political cultural terms ie as a required capacity for civic maturity and emotional allegiance to liberal institutions in a country that had experienced what lack of such maturity could entail and in the aftermath of 911 islamic radicalism was easily paralleled to germanys ghosts from the past its civic integrationist turn became dominated by the perceived need to make new liberal democrats out of traditional muslims and its crisis of multiculturalism came to denote not the failure of any cultural minority incorporation policy but the mere acceptance of civically unassimilated groups living their parallel lives in germany in recent years the conservative christian democrats has continued to frame citizenship as a reward for successful integration whereas the social democrats who have always lobbied for dual nationality and consider it a precondition for successful integration however as a result of the most recent grand coalition negotiations in the new merkel cabinet people from migrant backgrounds born in germany will for the first time be able to apply for dual citizenship rather than deciding for one nationality between the ages of 18 and 23 this policy change is most significant for the countrys sizable turkish population although it will uphold an existing dual nationality ban for later arrivals who choose to become german citizens there is now also crossparty consensus that germany is a multicultural immigration society even though chancellor merkel and others said that multiculturalism as a public policy has failed instead integration has become the buzzword in recent years under chancellor merkel in both political and educational debates with intercultural education being a strong component of the federal curricula frameworks in 2013 aydan özoğuz became the first ever woman with turkish roots and muslim member of the german federal government as minister of state for immigration refugees and integration another sign that underlines germanys revised approach towards diversity unlike germany denmark has had comparatively lower levels of contemporary immigration and historically in the early postwar period immigration only really originated from other nordic and western european countries during the 1960s and early 1970s guest workers were recruited from countries such as turkey yugoslavia and pakistan to undertake work which danes were not prepared to however the numbers were modest and after recruitment of guest workers was stopped in 1973 the main forms of immigration were family reunification and from the 1980s asylum today ethnic minorities from nonwestern countries comprise about six percent of the danish population of five million danish immigration and integration policies have passed through three stages neither of these may be called multiculturalism in any conventional positive sense larger municipalities have adopted street level diversity practices and use immigrant friendly discourse by contrast the negative attention at the national level to immigration related diversity per se and to all forms of minority recognition as well as attempts to curb diversity through tough asylum laws and integrationist measures in the name of danish fundamental values which must be accepted by people wanting to live here could be seen as emerging danish antimulticulturalism in the seventies and early eighties where numbers were low emphasis was on equal treatment and eliteled social tolerance this reflected a national selfimage as an open and tolerant country assister of its jews during the second world war and promoter of human rights principles in international relations while some worried that denmark now received families with roots in cultures which deviate strongly from the danish culture as one conservative mp put it he and others were concerned with how immigrants could come to live on an equal footing with danes in the welfare society in a context in which culture might become an obstacle to equality although most politicians would assume that some allowance should be made for immigrants to retain part of their customs not least because many were assumed to return to their countries of origin during the 1980s recession and borrowing from sweden denmark introduced local election rights after three years residence in 1981 and in 1983 one of the worlds most liberal asylum laws which included a de facto refugee category yet it took none of swedens positive steps towards official recognition of immigrants rights to freedom of cultural choice in the next stage during a significant influx of refugees in the 1980s which briefly placed immigration high on the agenda the onus was increasingly on the obligations of individual immigrants to make an effort to integrate into danish society the liberal asylum law was tightened and resulted in a serious political rift between the social democrats and the rest of the left the third stage from the late 1990s until recently was characterized by the high political saliency of immigration with a gradual shift of focus from labour market integration towards danish values integration active citizenship and attempts to counter islamic radicalisation the portrayal of immigration as a threat to national cohesion and national identity has emanated in particular from the populist danish peoples party which has played a pivotal role as a stable parliamentary support of the rightwing coalition government that was in power from 200111 while always more liberal than multicultural some policies did in fact accommodate minorities in the realms of language education and culture migrants ethnic organizations enjoyed some financial support until 2002 public funding was allocated to mother tongue teaching and denmark retains a publicly supported system originating in the nineteenth century of independent schools which also has been used to found muslim faith schools but the benign liberal approach did not last longer than a few years and never developed into anything like british or dutch multicultural public policy since the late eighties migrant minorities were called upon to take more responsibility for their functioning and adjustment to danish society particularly in terms of not burdening the welfare system in 1999 denmark took a sharp turn towards a more integrationist or effectively assimilationist approach introducing an integration act with a mandatory introduction programme including up to 2000 hours of language training in all legislation respect for cultural identity is omitted and selfsupport became the overall goal the integrationistassimilationist approach was intensified after the 2001 election which had focussed on unemployment and welfare costs of immigrants a new lower introduction benefit was introduced for new immigrants along with integration contracts and severe restrictions in family reunification rights the new rightwing coalition now made systematic use of the concept of medborgerskab or good citizenship as distinct from legal citizenship emphasising that one could be a good citizen without enjoying the political rights possessed by legal citizens and indeed that proving ones capacity for the former was a precondition of aspiring to the latter danish antimulticulturalism in the absence of any special rights or programs to dismantle increasingly centred on limiting diversity through the tightening of membership access in consecutive agreements between the danish peoples party and the government between 2002 and 2010 eg with longer required period of legal residence a very difficult history politics and high culture citizenship test and an extremely tough language requirement which effectively blocked citizenship for most noneuropean and nonacademic applicants access to permanent residence and family reunification was also progressively tightened throughout the period eg with the introduction of a complicated point system rewarding labour market activity language facility educational level and voluntary active citizenship following 911 the government focused increasingly on defending liberal values such as freedom of expression personal autonomy separation of politics and religion and tolerance this issue exploded with the publication in jyllandsposten in september 2005 of cartoons depicting the prophet muhammad to test alleged problems of selfcensorship and encourage muslims to accept scorn mockery and ridicule to be able to live in a secular democracy the episode illustrates well how danish citizenship culture had become increasingly identityrelated in ways that made it appropriate to speak of a culturalised civic nationalism whereby political and public life was awash with notions of an egalitarian and liberal democratic superiority which was presented however as embedded in the particularity of danish national history there was a sense that universal values are realised more or in a better way here than elsewhere or even that acquiring such citizenship qualities was the function of a long historical heritage a peculiar national vaerdikamp was staged not so much over the actual semantic content of danish values but over whether these values were threatened by should be defined in contrast to or had to be defended against an increasingly essentialised islamic other while much of the danish version of the leitkultur debate the change of government was also a change in discourse the previous government had overplayed its hand with yet more proposals in 2010 for tightened border controls and naturalisation and thorningschmidt rightly sensed that the electorate thought that tightening had gone too far or at least far enough the new government pledged to create a new balance where integration gets priority over exclusion spoke of immigrants as regular citizens with rights who wanted the same things as everybody else and called for more decency and respect in immigration and citizenship policies promising that all those who wish to be part of denmark should not constantly be met with new unreasonable demands opinion polls consistently confirm high and growing levels of social tolerance in denmark also compared to most other european countries and its metropolitan everyday multiculturalism remains in place but debates about islam and integration continue albeit at a lower level after the financial crises has shifted public attention towards the more immediate issues of unemployment and the fiscal sustainability of the welfare state the normative content of denmarks civic turn remains comprehensive combative and egalitarian wayoflifeoriented as in the netherlands but also culturalised and ethnicised in a backward looking way which sits uneasily with any sensitivity to cultural diversity unlike either germany or britain the danish leitkultur and concern with good citizenship harbour little selfdoubt integrating immigrants muslims mainly is still about teaching them the liberal democratic virtues traditions of active citizenship and egalitarian norms that nonmuslims danish society is deemed to possess in abundance already conclusions complicating the retreat in several cases our survey of the emergence of civic and other allegedly postmulticultural developments in these four countries points to both the resilient and porous nature of national models they are resilient where institutional opportunity structures have embedded and sedimented multiculturalist public policies to a greater or lesser extent but they are more porous where anxieties over islam are repeatedly observable across the different national frames of denmark germany and also the netherlands these centre on separatism in general and muslim alienation estrangement in particular indeed banting and kymlicka point to a relationship between antimulticulturalism and illiberal practices perceived to be manifested within the kind of culture that is being accommodated more precisely it is very difficult to get public support for multiculturalism policies if the groups that are the main beneficiaries of these policies are perceived to be carriers of illiberal cultural in order to maintain these practices elsewhere kymlicka narrows this further in his conclusion that if we put western democracies on a continuum in terms of the proportion of immigrants who are muslim i think this would provide a good indicator of public opposition to multiculturalism across our cases the evidence supports the reading that citizenship have explicitly shifted onto the identity of membership itself but our discussion shows how the provenance of this development is in fact quite mixed taking into account issues of social capital in the uk integration and national unity in the netherlands social welfarism in denmark and to some extent national identity in germany that is not to say that there are no convergences even unlikely ones for example it is striking to note the similarity in the dutch and danish cases although there was more multiculturalist policy in the former than in the latter the combined danish onthe ground municipal accommodation together with targeted social policy resembles multicultural governance in the netherlands indeed in both cases a sharper secularism and ethnicised conception of the nation cuts against the grain of a more pluralist nationhood in britain comparing germany to the netherlands and britain meanwhile is to observe a number of points the first and most obvious is that the critique of multiculturalism and parallel societies has been noticeably robust in a country which has seen little multiculturalism in the first place the second is to register that claimsmaking has been minimal though not absent and has come from a largely disenfranchised migrant and migrant descendant population here one might point to the role of the church whose institutional entrenchment in the welfare state delayed and watered down german implementation of eu antidiscrimination legislation or indeed the continuing hold of the countrys historical legacy of a language culture and descent based conception of volk which was not legally challenged at least in part because of post war partition and the political necessity to provide for natural german citizens in the east the point in each case is that the extent to which this marks a retreat of multiculturalism needs to be set against the background that there is no simple account of an advance of multiculturalism in each country in the first place that is to say that whereas some accounts employ the narrative of a relatively seamless swing in the pendulum that has moved the momentum from being in favour to being against multicultural policies we find it difficult not to observe how the momentum behind this pendulum has been staggered across different national contexts with different starting point in this journey that is to say that in our analysis of the present fate of multiculturalism as a public policy something concerned with the remaking of public identities in order to achieve an equality of citizenship that is neither merely individualistic nor premised on assimilation we must not ignore how the pattern of its development in different national contexts is neither linear nor unbroken this substantiates a reading of incremental adaptation which argues that change takes place even in the context of stability in formal programs though processes of drift conversion and layering the implication being that where there have been advances in policies of multiculturalism these have not been repealed uniformly nor on occasion at all but may equally have been supplemented or balanced out in civic integrationist approaches in europe and a number of journal articles on the intersection of migration and education notably curriculum design and development as well as diversity management nynke de witte is a senior researcher at the dutch court of audit and specializes in the evaluation of government policies her academic research focuses on european challenges of multiculturalism and the role of faithbased organizations in european cities since 2005 applicants for citizenship have been required to show their commitment to the free and democratic order of the constitution of the republic of germany an obligatory commitment which stems from the belief that immigrants need to be publicly reminded of the primacy of the german constitution this led to a slew of new legislation such as the immigration law which is geared toward integration strategies and the invitation to migrants and civil society actors to take part in four national integration summits further islam conferences have sought to focus on the interaction between the national majority and muslim minorities each of these are said to comprise milestones in that they speak with minorities and not solely about them this is evident in the federal commissioner for integration maria böhmers statement in which she revised an earlier position in stating germany is not an immigration country but an integration country to this end formal citizenship can be acquired through a process of naturalisation after eight years of legal residence provided the applicant has sufficient german language skills and other civic competencies the amendment to the citizenship law means that the children of foreigners now automatically acquire german citizenship if one parent has been legally residing in germany for at least eight years with a right to abode permit these children can retain dual nationality until the age of twentythree after which they have to choose between german citizenship and the citizenship of their parents in 2010 thilo sarrazin published a controversial book entitled germany is doing away with itself which sold over one million copies and sparked a long and often heated debate over culture and integration in germany in his book sarrazin denounces the failure of germanys postwar immigration policy he advocates a restrictive immigration policy with the exception of the highly skilled and the reduction of state welfare benefits and describes many arab and turkish immigrants as unwilling to integrate he calculates that muslim population growth may well overwhelm the german population within a couple of generations at the current rate and that their intelligence is lower as well polls at the manner very similar to the netherlands was about standing up for the comprehensive egalitarianism and feminism of social democratic state institutions which always aimed to liberate its citizens it also concerned fear that diversity in and by itself would jeopardize the trust solidarity and cohesion of a small but open society which historically celebrated its tribelike sameness as a resource against the world much as germany relative to the netherlands and britain denmark was slow to accept its status as an immigration country and to follow its neighbour swedens initiatives in the field of active labour market integration policies let alone antidiscrimination this as well as its choice to part company with both norway and sweden in the field of citizenship and residence policy was partly due to party political electoral and coalitionlogic reasons above all the role of a politically very capable new right party and partly the hold of a particular ethnocultural citizenship and national identity tradition which emanated from nineteenth century wars with germany and subsequent loss of territory and which continued to value the idea of cultural homogeneity even as old style danishness had become diluted this trajectory significantly contrasts with swedish state modernism always prevented denmark from combining its deepseated social egalitarianism with serious susceptibility to multiculturalism

there is a widely shared view that the appeal of multiculturalism as a public policy has suffered considerable political damage in many european states the turn to civic measures and discourses has been deemed more suitable for the objectives of minority integration and the promotion of preferred modes of social and political unity it is therefore said that the first decade of the new century has been characterised by a reorientation in immigrant integration policies from liberal culturalist to the return of assimilation brubaker 2001 on route to a broader retreat from multiculturalism joppke 2004 in this article we argue that such portrayals mask a tendency that is more complicated in some cases and much less evident in others to elaborate this we offer a detailed account of the inception and then alleged movement away from positions in favour multiculturalism in two countries that have adopted different versions of it namely the uk and the netherlands and two countries that have historically rejected multiculturalism namely denmark and germany we argue that while there is undoubtedly a rhetorical separation between multiculturalism and civic integration the latter is in some cases building on the former and broadly needs to be understood as more than a retreat of multiculturalism taking seriously banting and kymlickas argument that understanding the evolution of integration requires the the mindset of an archaeologist we offer a policy genealogy that allows us to set the backlash against multiculturalism in context in manner that explicates its provenance permutations and implications

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introduction assessing researchers productivity and impact is increasingly being metricated and the number of citations is one of the main measures that is used this occurs at an individual level in promotion and hiring decisions and increasingly at an institutional level in evaluating whole departments and universities in the uk the research excellence framework intends to use citation analysis along with peer review in future decisions about the allocation of research funding there are many complex issues involved in using metrics for this purpose and the higher education funding council for england has commissioned several reports and is currently undertaking a pilot exercise one of the major problems especially in the social science is the source of the citations the primary database has conventionally been thompsons isi web of science which records all citations from papers in about 8700 journals whilst this coverage is reasonable in many of the sciences it is acknowledged to be limited in social science partly because many journals are not included and partly because much research is published in books and conferences which are not covered at all in recent years alternatives have been developed that work in a similar manner eg scopus but one of the main rivals is google scholar this works in a different fashion by searching the internet and other digital repositories to find citations in a wide range of sources several studies have compared the two sources in general and in particular disciplines while hefces commissioned reports have concentrated mainly on the sciences because of the known problems in the social science their pilot exercise for example includes almost no social science subjects no one that we are aware of has looked specifically at the business and management literature in terms of a direct comparison between web of science and google scholar there has been other scientometric analysis of business and management for example journal rankings factors affecting citations received by a paper and statistical models of citation behaviour so the purpose of this paper is to investigate the extent to which wos and gs do in fact record research outputs and citations in business and management and to discover whether there are any particular patterns in their coverage or lack of it to do this we have taken all the publications of academics at a uk business school over the period 20012007 together with a selection from earlier years and processed them through wos and gs in the first section after a review of the literature on this area we also discuss the results of several surveys and reports carried out in the uk based on the submissions to the 2001 research assessment exercise web of science and google scholar general studies in the past the main and indeed only significant source of citation data were the isi citation indices that have now become known as the web of science this covers over 12000 primarily englishlanguage journals out of approximately 22500 refereed journals listed in ulrichs periodicals directory it is beginning to include conference proceedings but does not include reports or books wos records every paper published in these journals together with their citations and then allows access in a variety of ways including citation reports on journals and individual authors in recent years a range of bibliometric databases have emerged some discipline specific such as the acm digital library and some generic such as elseviers scopus these are of three types i those that involve searching the full text of the document for citations where the text may be contained in the database or may be home pages and repositories on the web ii those that allow the user to search the cited reference field of the document and iii those like wos that are primarily designed for capturing citations several studies have been carried out comparing these different sources often in different disciplines and meho and yang provide a good overview in this study we limit ourselves to comparing wos with gs specifically in the discipline of business and management the two databases have very different modes of operation wos has a clearly specified list of journals and records all the citations from those journals its coverage is generally considered to be good in many of the natural sciences but poor in the social sciences and humanities it has tools that help with the unique identification of authorsone of the major problems in collecting accurate citations in contrast gs has a scope and reliability that is in general unknown it searches web pages and also has access to the websites of certain publishers and can sometimes provide full text but the exact details remain secret the results generally have a wide coverage but can include many works that are not specifically research oriented eg teaching notes discussions and reports it is relatively difficult to pin down a specific author especially if they have a common name and often the bibliographic details of the citing sources are wrong or incomplete hence getting accurate results is extremely time consuming meho and yang in their study of the publications of a school of library and information science found that 42 of gs citations came from journals 34 from conference papers 10 from dissertations and theses and 14 from other sources they found 2023 citations to their source documents in wos 2301 in scopus and 4181 in gs combining wos and scopus produced 2733 unique citations while including those from gs pushed the total up to 5285 thus wos produced only 48 of the citations in gs and only 38 of the citations generated by a combination of all three walters studied 155 core articles in the area of laterlife migration across a range of citation databases gs had the greatest coverage and wos next best with 73 whilst this study did not look at citations it did examine the range of sources used by gs in terms of publishers and found no undue bias ma et al report a study using the chinese version of google scholar whilst it is clear that wos is worse than gs in social science this is not the case in natural science barilan evaluated the hindex a measure of research productivity based on citations for 40 highlycited israeli scientists in all subject areas except mathematics and computer science wos produced significantly more citations than gs this is probably attributable to the importance of conference proceedings in computer science studies on the uk the centre for science and technology studies at leiden has presented several commissioned reports both for hefce and for the esrc in 2008 they analysed the submissions to the 2001 rae looking in the main at the science subjects they did however do some analysis across all units of assessment table 1 shows the coverage of outputs in wos we can see that economics has the best coverage with 68 of its total outputs in wos rising to 78 of the journal papers however b m generally has only 38 covered and accounting and finance a mere 22 the latter result is because a significant number of high quality accounting and finance journals are not included in wos table 1 about here a further cwts report specifically compared wos with scopus a citation index launched recently by elsevier the comparative results can also be seen in table 1 with scopus having a better coverage especially in accounting and finance the results are still generally under 50 however norris and oppenheim also evaluated bibliometric databases for the esrc concentrating on the social sciences they worked at the level of journals and identified 4594 clear and unique journal titles containing a total of 33533 submitted papers table 2 shows the proportions of these journals that are included in three databases wos scopus and cambridge scientific abstracts illumina table 2 about here google scholar was not evaluated in terms of individual uoas only in aggregate a random sample 380 journals across all subjects were searched for in gs of these 4 found no matching records 10 found citationonly recordsie only citations in other papers bibliographies while 86 found websites listing the journal the results for wos are not inconsistent with those in table 1 although at the journal level a lower was found in economics and a significantly higher in accounting one possible explanation for this is that the economics papers are more concentrated in the main journals that are included in wos while in accounting they are more scattered into journals not included the scopus results are again better than the wos ones gs has a much greater overall coverage although as has been discussed its scope and reliability are uncertain the researchers also looked at the mean citations per paper for a sample of articles with the results shown clearly csa was very out of line with few citations and gs produced significantly more because of its wider base of sources mahdi et al conducted an analysis of the 2001 rae to see to what extent citations correlated with the outcomes of the rae their general conclusions were that there was a reasonable degree of correlation in some subjects in the sciences but that the coverage of wos in the social sciences and humanities was quite problematic while 89 of outputs in biomedical sciences were found in wos the corresponding figures for social science and arts and humanities were 35 and 13 table 3 about here the more detailed results are shown in table 3 we can immediately see an anomaly with table 1 since both are supposedly measuring the submitted papers found in wos by uoa the figures are significantly different being higher in mahdi et al and we can find no explanation for this partly because mahdi et al give very little description of their actual methodology the results also give mean citations per paper for the two uoas which had at least 20 institutions with at least 20 matching papers it was also found that economics and business and management were subjects where there was a relatively high correlation between citation rates and rae ranking evidence ltd conducted research for esrc producing a bibliometric profile for selected disciplines including business and management accounting and economics the main results are shown in table 4 it is worrying that once again the results are not particularly close to those in tables 1 and3 this no doubt reflects in part the difficulties of unambiguously identifying individual papers in these databases and differing practices over what to do with ambiguous references but it is noticeable that there is not even agreement on the total number of submitted outputs to the rae table 4 about here the research also looked in detail at the number of cites per paper for those papers that could be found in wos but only for the departments graded as 4 5 or 5 the number of citations is obviously time dependent so these figures will be an average across the period of the rae ie papers published in 1995 would have five years of citations those published in 2000 only one year these figures are higher than those in table 3 because they only include the 4 and above departments accounting and finance is particularly low partly because so few journals are included in wos thus restricting the number of citations that can be found citation rates normalised to the rates for the disciplinary field were also calculated in this approach results above 10 show that the publications are generating more citations than the average for the field the figures for business and management were 147 190 and 227 showing both high impact and that the impact increases with the rae grade the equivalent figures for accounting are 028 082 and 107 showing that it is not simply the lack of wos journalsaccounting departments especially at the lower end gain relatively very few citations assessing the outputs of three uk business schools the data we have analysed consisted of over 4600 research outputs produced by staff at three uk business school primarily from 2001 to 2007 although including some from earlier years the three schools are of similar sizes but different characteristics school a is relatively new as a business school but is at a worldleading university and scored very highly in the rae school b is also relatively new at a traditional university and has expanded considerably in recent years school c is at a 1960s university and is moving from being mainly teaching oriented to being research intensive b and c are in the top third of uk business schools a summary of the schools is provided in table 5 details about the number and types of publications is in table 6 it is interesting to note the very high number of authors involved with the papers compared with the number of staff actually submitted in the rae this shows that the majority of papers have multiple authors and that these are commonly located in other institutions table 5 about here each publication was individually looked up in gs and wos this is a very timeconsuming exercise especially for gs since the quality of the data is poorthere are often multiple entries for a single item because the forms of reference are inconsistent or inaccurate table 6 shows the main results we have included all publication types even though many would not be submitted to a ref we will initially look at the results overall then discuss differences between the schools we can see that the majority of the outputs are journal papers with the next category being conference papers this implies that 55 of the outputs are immediately excluded from analysis in wos looking first at the gs coverage we found 66 of all the publications including 89 of the journal papersa very significant proportion surprisingly perhaps given the high presence of publishers websites only 74 of books and 76 of edited books were found other areas of low coverage were conferences and reports in contrast wos would only cover journal papers and only found 48 of those in the sample on some occasions the journal was apparently on the wos list but the actual paper did not appear this was generally found to be because the journal was not part of wos at the time that the paper was published sometimes because there was a gap in the journal history table 6 about here moving to citations gs found a considerable number for all publication types the mean citations per paper were highest for books and edited books with the figure for journal papers being 147 wos found 8434 citations for the 1004 papers it included giving a cpp of 84 we also looked to see if these proportions had changed over time but in both cases there were yeartoyear variations but no apparent trend thus it is not the case that either source is improving its coverage it could be argued that if the purpose of using these measures is to compare departments or research centres then it doesnt really matter about the absolute level of coverageit would be the same for all however this assumes either that the coverage rates are the same for all subject areas or that all departments will have the same mix of subject areas so that differences would not matter we can throw some light on this by considering the extent to which these general results differ between schools looking firstly at journal articles we can see a significant difference in cpp between the schools in gs school a has a cpp of 215 compared with 109 and 102 for b and c the results are similar but not identical with wos where the figures are 114 76 and 52 respectively thus using gs a is twice as good as b and c which are almost identical while using wos a has less of an advantage and there is a clear difference between b and c looking at the relative coverage all three are very similar in gs but in wos b has significantly less overall if we are only interested in relative rather than absolute levels then both gs and wos show school a to be the best by a distance but they disagree between b and c looking at the other types of publications where there cannot be a comparison the main feature is that a and c have very similar values for cpp in all categories but that b is generally lower looking at cpp for all outputs the differences between the schools narrows the research of a business school tends to cover a wide range of subject areas and not all of them are directly classified as business and management the publications we are analysing can be split into different areas or fields depending on how the journals are classified within wos the results are shown in table 7 where we can see that the papers come from nine different subjects from agricultural economics to mathematics and information systems this is very important if the leiden methodology is used as it normalises citations per paper to the mean for the appropriate field for the paper but how does one determine how many fields there should be and what they are for example should business and management be classified as one field or are there subfields within it which have significantly different citation behaviours in table 6 we have taken all the papers and classified them into a field based on the definitions and journals from web of science we have included in this journals that are not themselves included in wos we have then amalgamated 62 subcategories into 9 major ones table 7 about here an anova shows that the three main effects are all significant at less than 1 also the interaction between school and source and between school and subject are significant but that between source and subject is not considering the cpps across subjects we can see that there are considerable differences from 288121 in business and 28184 in is and computer science down to 9442 in agriculture and 10758 in engineering this certainly suggests that there are significant difference in subjects within business and management overall caution must be exercised as this is only a relatively small sample covering three business schools it could be that these schools are particularly good or bad at these subjects in comparison with business schools generally but the differences are so large that this is unlikely to explain the full effect this suggests that any form of the leiden methodology would need to be normed against subdisciplines within management not management as a whole as different schools may have different mixes of subjects comparing the sources generally the cpp for wos is under half that of gs but there is quite a degree of variability it is lowest in economics and highest in mathematics and statistics clearly in some instances there are small sample numbers for the general management field the wos cpp is 99 which is 44 of the gs figure a ratio that is in general agreement with many of the other evaluations in the literature although these interactions are not statistically significant on this sample it certainly suggests that wos would treat some subjects particularly badly as we would have expected there were significant differences between the schools and there was also an interaction with the subjectsfor example school b gets particularly low citations in is and computer science table 8 about here at the lowest resolution level we can look at individual members of staff in table 8 we have looked individually at all the staff from business school c to keep the table to a reasonable size these appear in order of number of publications and have been anonymised we can see there is a high degree of variability especially in cpp which reflects differences both in papers and citations in the two data sources overall the proportion of papers found is much higher and more consistent in gs with the mean proportion being 71 against 24 there are some interesting anomalies which show the wide degree of variability in results that come from wos person 4 has 55 outputs but only 4 appear in wos with zero citations this is because they are mainly conference papers and reports in contrast person 11 has a very high level of cpp in wos as much as in gs with 13 cites per paper although only 8 of their papers are in wos they are all relatively highly cited conclusions this study has limitations in that it considers the publications of only three uk business schools albeit reasonably representative ones and in some of the subfields there are relatively few publications nevertheless the results seem fairly clear the knowledge produced by academic researchers is increasingly being judged not just in terms of where it is published but in terms of what impact it is having currently the major metric for impact is the number of citations that papers authors departments or journals receive this however depends on the source from which the citations are counted the traditional citation indexthe web of scienceis reasonable in the sciences but has poor coverage of social science in this paper we have compared wos with a more recent and rather different competitor google scholaron the publications of three university business schools the results show that wos picks up less than half of the journals papers and citations found by gs moreover the results differ significantly between subject areas within business and management making it difficult to compare departments or individuals that might have different subject mixes google scholar on the other hand suffers from unreliable data and a lack of transparency about its sources but overall it provides a more comprehensive and less subjectdependent citation resource the conclusion is that at this point in time citationbased evaluation especially using the leiden cites per paper metric is certainly not feasible using web of science more consistent results could be gained from google scholar but here there are significant problems of data reliability and transparency

assessing the quality of the knowledge produced by business and management academics is increasing being metricated moreover emphasis is being placed on the impact of the research rather than simply where it is published the main metric for impact is the number of citations a paper receives traditionally this data has come from the isi web of science but research has shown that this has poor coverage in the social sciences a newer and different source for citations is google scholar in this paper we compare the two on a dataset of over 1200 publications from a uk business school the results show that web of science is indeed poor in the area of management and that google scholar whilst somewhat unreliable has a much better coverage the conclusion is that web of science should not be used for measuring research impact in management

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i introduction collaborative coding environments 1 like github make it easier to contribute to software projects however these environments also make the evaluated contributions a challenging task to project managers and code reviewers 4 for two reasons first developers with wide ranges of experience work simultaneously on the same projects second developers can perform contributions along software development that may lead to the introduction of bugs 2 in spite of these challenges collaborative code environments provide a rich source of data this data can be explored to extract information on technical and social factors related to developers understanding the relation between those factors and the introduction of bugs may be useful for project managers and code reviewers for example let us consider the case a developer with bugrelated factors decides to perform a pull request in a project thus code reviewers might want to double check this contribution potentially avoiding the introduction of a bug previous studies 1 3 10 have used these factors to perform different analyses on developers contributions for instance studies 1 3 4 indicate that both technical and social factors impact the acceptance rate of contributions on github however these studies did not analyze the influence of these factors on the introduction of bugs other studies 5 10 evaluated this influence only considering proprietary projects 6 8 9 or a reduced number of factors as well as characteristics to represent them 8 10 to improve the understanding on the relation between technical social factors and introduction of bugs we present a broader study involving five technical and three social factors in particular we analyze factors related to the developers experience 5 6 13 14 developers habit to follow wellknown technical contribution norms 1 ownership 8 12 14 nature of developers changes 15 bugginess of developers commits 5 communication with the community of a project 7 social influence on contributions 1 and the project establishment 1 first we investigate how commits that introduce bugs differ from commits that are not involved in the introduction of bugs in terms of these factors then we analyze how strong is the difference between buggy and clean commits finally we evaluate the effect of each factor on commit bugginess when considering the presence of multiple factors to perform our study we collect data from eight opensource projects hosted on github in particular we collect 6537 bug reports and compute 19 metrics we use these metrics to characterize the factors analyzed our study led to four main findings both technical and social factors are able to discriminate between buggy and clean commits technical factors are more determining to differentiate buggy commits from clean commits the developers habits of not following technical contribution norms and the developers commit bugginess are associated with an increase on the likelihood of a new commit being buggy and finally the projects establishment the ownership level of developers commit and the social influence are related to a lower chance of introducing bugs these findings shed light towards improving stateoftheart techniques that may assist code reviewers during the inspection of bugs the remainder of this paper is structured as follows section ii presents the design of the empirical study while its results are presented in section iii section iv discuss our findings section v presents the threats to validity section vi discusses the related work on commit bugginess finally section vii concludes this paper ii study design opensource environments like github enable developers with different technical capabilities and social interactions to contribute actively and simultaneously on the same software project also developers may perform a variety of activities for instance push commits openclose pull requests and issues as well as discuss about contributions although developers can collaborate on different projects their technical capabilities and social interactions may be determining factors to the software quality for example a developer that has never communicated with others involved in a project may not have enough knowledge about it and therefore he may inadvertently introduce bugs when performing a commit in this context our study investigates the relation between technical social factors and the introduction of bugs in opensource software projects to do so we define two research questions rq1 do bugintroducing commits differ from clean commits in terms of technical and social factors how strong is the difference understanding which factors are more related to buggy or clean commits may help code reviewers to avoid the introduction of bugs during the software development for example if the number of modified files in buggy commits is greater than clean commits code reviewers may want to double check commits with a high number of modified files hence rq1 aims at investigating if there is a statistically significant difference and how strong the difference is 32 between buggy and clean commits by considering technical and social factors rq2 in the presence of multiple factors what factors most affect the bugginess of a commit in the previous research question we analyze which factors are able to discriminate between buggy and clean commits as well as how strong is this difference however during software development the influence of different factors may contribute to commit bugginess 5 7 10 12 13 these studies analyze the effects of factors in isolation without considering the simultaneous influence of different factors for example the commit size and developers experience may simultaneously contribute to commit bugginess hence the rq2 aims at investigating the effect of each factor on commit bugginess by considering the presence of other factors a technical and social factors to answer our research questions we analyze five technical and three social factors the former factors are related to technical contributions developers experience in a project developers habit to follow wellknown technical contribution norms nature of a developers commits bugginess of a developers commits and project establishment the next three factors are social ones and capture interactions among developers in projects we focus on ownership level of developers commits comments performed by developers and their social influence we selected these factors since they were previously considered in studies involving opensource environments 1 3 5 11 18 each studied factor and their motivations are detailed below 1 developers experience although previous studies have assessed the influence of developers experience on the likelihood of their commits being buggy 5 6 13 14 they presented contradictory conclusions about this relation while eyolfson et al 5 and rahman devanbu 14 show that experienced developers are less likely to introduce bugs mockus 6 and tufano et al 13 indicate that more experienced developers are more likely to introduce bugs the contradictory findings indicated by these studies lead us to investigate again some of their analyses however these studies have assessed the influence of developers experience by considering only their number of previous commits or the number of days in which they have been associated with a project therefore we also use data about the code review process to characterize the developers experience hence we analyze f1 to enhance the understanding on the relationship between developers experience and commit bugginess 2 developers habit to follow technical contribution norms studies 1 18 indicate that project managers and code reviewers prefer to receive contributions that follow certain norms such as the inclusion of tests commits with a lower number of files changed and a higher legibility their goal is to improve the software quality moreover other studies 2 6 11 assessed quality measures associated with technical contribution norms and their influence on commit bugginess however none of these studies assess the relation between the habit of following technical contribution norms and commit bugginess for example if the developers commits include tests or involve only with small pieces of code do these commits tend to insert fewer bugs hence we analyze the f2 factor which wants to investigate the relation between following technical contribution norms and the commit bugginess 3 nature of developers commits previous studies on commit bugginess 9 11 19 state that bugfix commits are more likely to introduce a new bug in the software this finding indicates that the nature of a commit may be a relevant indicator of bugginess in addition studies 15 17 provide commit classification strategies able to recognize the nature of a code change based on these strategies we define the f3 factor to evaluate the relation between the nature of developers commits and their bugginess 4 developers commits bugginess bugginess is the likelihood of a commit to introduce a bug the bugginess of developers commits is commonly used as a relevant factor in previous studies 5 6 11 14 eyolfson et al 5 used the percentage of developers commits that are buggy to determine how buggy a developers commits are however these studies did not evaluate if a developers commit bugginess may influence the introduction of new bugs for instance is a developer whose commits are mostly buggy more likely to introduce bugs in the future thus we study f4 to investigate the relation between developers commits bugginess and the introduction of new bugs 5 project establishment opensource projects are constantly evolving growing and attracting new developers and followers who eventually will demand an increase in the stability of the project 20 as a project becomes more stable other important projects may become dependent on that project 18 thus in light of these concerns code reviewers of more established projects may be much more conservative and careful when accepting new contributions 1 hence we define the f5 factor which aims at investigating whether the establishment of a project affects commit bugginess 6 ownership level of developers commits prior work 8 12 14 have studied the ownership level of developers in a source code code ownership means how much a developer is responsible for the code committed to the repository the lower the ownership level of a developer in a code more developers are working on it and consequently the higher the interactions among those developers through the source code these studies 8 12 14 focus only on the ownership of a particular source code entity eg files our work has a commit granularity level using the ownership of each file modified in that commit there is no work analyzing the relationship between a developers ownership in a commit level and commit bugginess therefore in our study we want to analyze if a developer that works mostly on his own code is less likely to introduce bugs 7 communication with the community of a project a previous study 7 analyzed the relation between the communication among developers and the introduction of bugs the results suggest that bugintroducing committers discuss significantly less than other committers in this study the authors considered only the interaction among developers in the bugtracking system of two projects however opensource environments 1 18 support the communication among developers in different ways for instance github supports discussions about feature implementation and bug fixes through pull requests report bugs or request features through issues or changes made in a specific commit our intuition is that those different ways of communicating in a project community should be also considered when one investigates the effects on commit bugginess hence f7 considers all these communication forms as part of the conversation of a developer with the community this way we analyze the relation between commit bugginess and the amount of developers communication with the community of a project hosted on github 8 social influence on contributions along the evolution of a opensource project its developers perform a variety of actions and contributions these include follow other developers reviewing a source code opening or closing pull requests or issues such actions and contributions are the mean in which developers play the roles as a consequence these developers become increasingly influential in the community our goal is to investigate how this influence affects the commit bugginess of these developers b metrics developers experience we use three metrics to characterize the developers experience in a project our intuition is that the higher the value of these metrics the more a developer understands the project and its source code and therefore the more experienced he is to compute the values of each metric we consider the interval between the first developers commit to a project and the instants in which the commits authored by him were pushed these metrics are detailed below • experience this metric quantifies experience as the number of commits authored by a developer 11 • recent experience to measure the recent experience we consider the developers experience weighted by the age of his previous changes as defined by 11 by using the rexp we give a higher weight to more recent changes as a consequence we can attribute more experience to developers who have contributed recently • file experience it measures the developers experience in the files modified in a commit authored by him particularly for each file modified in a commit we define the developers experience as the number of previous commits authored by him on this file then we compute this metric as the sum of the experience in each file technical contribution norms we use five metrics to characterize the factor related to the technical contribution norms such metrics are based on the norms described in the work of tsay at al 1 which analyzed the influence of the presence of tests in commits on the acceptance of pull requests in our study we can analyze for example if the higher the presence of tests in the developers commits the more compliant with technical contribution norms the developer is • tests this metric measures the percentage of developers commits that contain tests studies 1 18 indicate that reviewers prefer contributions containing tests because they are likely to be more reliable hence we define the tp metric to measure how reliable developers contributions are to extract this metric we adopt the procedure described in previous work 1 as the authors report a high accuracy • modified files this metric counts the number of files modified in a commit the motivation for this metric relies on studies 1 22 that indicate large contributions are harder to understand or evaluate by project reviewers • median of modified files it measures the median of modified files among all the commits authored by a developer this metric was defined to characterize the usual behavior of developers in terms of the number of files modified in their commits by calculating the median of modified files we can investigate for instance if developers that constantly modify many files are more likely to introduce bugs • changed lines it represents the number of changed lines in a commit a changed line can consist of its addition or a deletion in a commit • median of changed lines it represents the median of changed lines among all the commits authored by a developer we define the cl and mcl metrics as complementary metrics of mf and mmf respectively aiming at characterizing the legibility of developers contributions we compute the mf and cl metrics by considering the instant that the commits were pushed in a project to extract the tp mmf and mcl metrics we adopted the same interval used to compute the experience metrics nature of commits we use four metrics to characterize the nature of developers commits these metrics are based on the classification of commit natures described in hattori lanza 15 the authors define four categories of commits based on a keyword analysis of the textual content in their messages forward engineering reengineering corrective engineering and management our intuition is that the higher the value of these metrics the more a developer is focused on a specific commit nature the process of computing such metrics was the same adopted for the experience metrics the measure of the metrics is the percentage of commits classified for each category and named as forward engineering reengineering corrective engineering management commits bugginess inevitably during the software development process developers make changes that introduce bugs 2 in this context we analyze if the commits of developers who have previously introduced bugs are more likely to be buggy to measure this factor we evaluate the percentage of buggy commits previously authored by a developer our intuition is that the higher the value of this metric the more harmful developers commits are the process of computing this metric is the same adopted for the developers experience metrics project establishment we measure the establishment of a project as the age of a project since its first commit ie how long a project has existed on github such metric was defined by tsay et al 1 and our intuition is that the higher the value of this metric the more mature and therefore established a project is we compute this metric at the instant that a commit was pushed ownership level we use two metrics to characterize the ownership level factor our intuition is that the higher the value of these metrics the lower the interaction among developers in a source code we describe these metrics below • commit ownership this metric measures how much a developer owns the files modified in a commit that he authored for each modified file we measure the ownership of a developer in a file as 1 d where d is the number of developers that previously authored a commit involving the file then we define the ownership level of a developer in a commit as the median of the files ownerships to compute this metric we consider the instant that a commit was pushed to a project • median ownership it represents the median of the commits ownerships among all the commits authored by a developer the process of computing this metric is the same adopted for the developers experience metrics communication within the community during the software development developers can perform diverse activities on github for instance they can communicate with the community by posting comments about different topics in issues and pull requests such interactions may represent the involvement of a developer on a project in this context we evaluate the number of comments performed by a developer in a github repository our intuition is that the higher the value of this metric the more a developer is involved in a project the process of computing this metric is the same adopted when we compute the f1 metrics social influence on contributions we use five metrics to characterize the developers social influence in a project our intuition is that the higher the value of these metrics the higher the developers influence in a project c project selection we manually select eight github java projects the criteria to select the projects are the projects must be opensource and their changes history must be hosted on github this way we ensure the full access to the software history the projects must use the github issues as the default bugtracking tool this way we standardize our bug report analysis the projects must be currently active and have been maintained or evolved for a long period of time the main motivation to this criteria is to ensure that the projects are active and relevant to the github community and the projects must have a relevant number of reported bugs and involved developers this way we ensure that the projects have enough bugrelated data to be investigated table i summarizes the characteristics of the projects which have a high number of developers and a large number of commits and bugs associated with them moreover all projects have thousands of github stars that is a measure of community interest in a project 18 d collecting bug reports the github issues are used to keep track of tasks enhancements and bugs related to a project furthermore developers can associate labels with each issue to characterize it such as bug or enhancement after fixing the bug or implementing an enhancement the issue is closed to collect the reports of fixed bugs in the selected projects we mined the closed issues related to bugs existing in each project in order to identify these issues we verified the ones containing the bug or defect labels resulting in 6 537 bug reports from the eight projects analyzed furthermore we conducted a careful manual validation of the collected bug reports to guarantee that they are related to the report of bugs after the manual validation process we considered 5 034 github issues that were classified as actual bug reports and investigated in our study e locating bugintroducing changes during software development developers make changes in the source code that may introduce bugs we will further refer to these changes as bugintroducing changes 26 to locate these we implement the szz algorithm 2 which aims at identifying the commits that introduced a bug in a software project in this context the szz algorithm requires the commit that fixed a given bug hence we use a github strategy to identify these commits keywords regarding fixing and closing issues followed by an issue number will automatically close the issue in this way we assume the commit that closed the issue as being the commit that fixed the bug we employ the szz algorithm for each validated bug report from the eight selected projects as a result we obtain a total of 10 674 unique candidate bugintroducing changes in addition we conducted a careful manual validation on a sample of 922 bugintroducing changes reported by szz this sample presents a margin of error of 4 at a confidence level of 99 four pairs of researchers from our research lab validated this sample each pair was responsible for a fraction of the sample and each individual validated the same candidate bugintroducing changes to take into account possible subjectivity during the validation the researchers classified each candidate into four levels of certainty low moderate high and absolute in the cases the researchers of a pair classified a candidate very differently one of the authors solved the conflict after the validation procedure we obtained an accuracy of 65 for our szz implementation we conducted the validation due to the high numbers of falsepositives reported in previous studies 25 26 28 f data collection to collect the data used to compute the metrics related to technical and social factors we use the github api first we collect the public identifier on github of the developers that authored at least one commit in each of the studied projects then we mine all the commits issues pull requests and comments of a project finally we link the collected authors to the activities that they performed on the project through their usernames as a result of this process we obtain data about 2 949 developers which authored at least one commit in the repository moreover we collect 96 258 commits 33 244 pull requests 45 554 issues and 358 200 comments related to the eight projects analyzed g data analysis to answer rq1 we use the wilcoxon rank sum test 23 to verify which metrics are able to discriminate between buggy and clean commits this nonparametric test allows us to decide whether two populations are identical or not to ensure statistical significance we adopt the customary 05 significance level for this test since we are performing multiple comparisons we need to adjust the pvalues of the wilcoxon tests to take into account the increased chance of rejecting the null hypothesis simply due to random chance to do so we apply the widely used bonferroni correction 35 which controls the familywise error rate for this method we consider that each project is a family which means that we perform the correction in the pvalues of the metrics at the project level furthermore in rq1 we also use the cliffs delta measure 30 to evaluate how strong is the difference between buggy and clean commits in terms of the metrics analyzed similarly to the wilcoxon rank sum test the cliffs delta is a nonparametric effect size measure in order to interpret the cliffs delta effect size we employ a wellknown classification 31 it defines four categories of magnitude negligible small medium and large to answer the rq2 we evaluate the effect of each factor in the presence of the other ones to do so we create a multiple logistic regression model for each studied project where each metric is a predictor and the outcome variable is whether a commit is buggy or not in other words we create a regression model that predicts the likelihood of commit bugginess we choose a multiple logistic regression approach due to the fact that we are studying the effect of multiple predictors in a binary response variable we report the effect of the metrics in the likelihood of a commit being buggy in terms of odds ratios odds ratios are the increase or decrease in the odds of a commit being buggy occurring per unit value of a predictor an odds ratio 1 indicates a decrease in these odds while 1 indicates an increase since our metrics are heavily skewed we apply a log 2 transformation on the rightskewed predictors and a x 3 transformation on the left skewed to ensure that multicollinearity would not affect our model we remove the metrics which have a pairwise correlation coefficient above 07 29 moreover to ensure normality we normalize the continuous predictors in the model as a result the mean of each predictor is equaled to zero and the standard deviation to one finally to ensure statistical significance of the predictors we employ the customary 05 significance level for each predictor in the regression model we present the results of our analysis based on the 10674 unique candidate bugintroducing changes reported by the szz algorithm however we also perform the same analysis on the sample validated by the four pairs of researchers containing the 922 bugintroducing changes the results of both analysis are similar as can be seen in our replication package h replication package we provide a replication package 1 that contains the source code used in this study the data used in the analyses a detailed example of the methodology a deeper characterization of our dataset and details on the validation regarding the szz algorithm iii results the following section present the results for the two research questions rq1 do bugintroducing commits differ from clean commits in terms of technical and social factors how strong is the difference table ii presents the results of rq1 the first and seconds columns represent the technical and social factors and the metrics associated with them the remaining columns describe the metrics and their respective magnitudes of the cliffs delta related to each studied project we use the symbol to indicate if d was positive and otherwise in addition we use four levels to measure the strength of a magnitude and we do 1 f6 mo co f7 nc f8 exprev rexprev sc msd sd not use a symbol to represent this last level the cells in gray represent the pvalues of the metrics that obtained statistical significance in the wilcoxon rank sum test each factor is assessed in terms of n cases where n is given by the number of metrics multiplied by 8 we observe that the developers experience metrics obtain a statistically significant difference in 16 out of 24 cases analyzed the fexp metric presents statistical significance only in three projects the exp metric does not obtain statistical significance only in two projects the rexp metric presents even better results not obtaining a statistical significance only in one project regarding the technical contribution norms metrics they obtain statistical significance in a number of cases greater than the f1 metrics the f2 metrics obtain a statistically significant difference in 82 of the cases analyzed the cl and mf metrics present statistical significance in all projects while mcl is not statistically significant only in bazel regarding the f3 factor its metrics present statistical significance in 22 out of 32 cases analyzed particularly the fep metric obtains statistical significance in seven out of eight projects analyzed similarly to fep the rexp mcl cl mf and pbc metrics also obtain statistical significance in at least seven of the projects analyzed the age metric reaches even better results by obtaining statistical significance in all projects analyzed such results indicate that technical factors can discriminate between buggy and clean commits when observing the social factors both metrics characterizing the f6 factor present a statistical significance in the majority of the projects while the co metric obtains a statistically significant difference in six out of eight projects the mo metric is not statistically significant in three also we observe that the nc metric presents a statistical significance in six projects regarding the f8 factor the metrics present statistical significance in five out of the eight projects on the other hand no metric from this factor could reach statistical significance in the okhttp project note also that only exprev and rexprev are statistically significant in presto and only one metric presents statistical significance in bazel similarly to the technical factors the social factors can also discriminate between buggy and clean commits when we consider both the technical and social factors they obtain a statistically significant difference in 75 of the cases investigated while the technical metrics present statistical significance in 78 of the cases the social metrics present in 70 differently from technical metrics no social metric could reach a statistically significant difference in all the projects analyzed note that the technical metrics cl mf pbc and age present statistical significance in all projects both technical and social factors can be used as a good guideline to distinguish between clear and buggy commits however the technical factors present a proportion of statistical significance cases greater than the social ones we previously analyzed if there is a statistically significant difference between clean and buggy commits in terms of technical and social factors from now on we also investigate the magnitude of this difference positive magnitude notice that the technical metrics mcl mf cl and pbc present a positive magnitude in all projects analyzed indeed we observe that the cl metric obtains a large magnitude in all projects analyzed the mf and pbc metrics obtain a strength slightly lower than cl by reaching magnitudes between small and large we also observe that both the mcl and mmf reach magnitudes that varied from negligible up to medium while mcl presents a positive magnitude in all projects the mmf presents in seven ones finally all the f8 metrics present a small medium or large positive magnitudes in rxjava negative magnitude regarding the negative magnitudes the age metric presents negative magnitudes in six projects reaching a large one in springboot similarly to the age metric the rexp and rexprev metrics also present negative magnitudes in six projects however they obtain a strength equal or slightly lower than age in such projects we also observe that the f1 and f8 metrics present a negative magnitude varying from negligible to medium in the springboot and signalandroid respectively by analyzing both technical and social factors the metrics present positive magnitude in 54 of the cases if we consider only the statistically significant cases the metrics present positive magnitude in 60 of the cases also in the statistically significant cases the technical metrics cl mf and pbc present a small or large positive magnitude in all the projects analyzed this means that the buggy commits of these projects have a significant higher cl mf and pbc than clean commits differently from the technical factors we do not observe a tendency of positivenegative magnitude in the social metrics there are strong differences between clean and buggy commits in terms of technical and social factors moreover the positive magnitudes are more frequent than the negative ones again the technical factors are more determining than the social ones rq2 in the presence of multiple factors what factors most affect the bugginess of a commit in the rq1 we analyze the metrics individually now we use the odds ratios technique to investigate the effect of each metric on commit bugginess in the presence of other metrics analyzed in our study table iii summarizes the effects of the metrics on commit bugginess in each project the first column represents the technical and social factors the remaining columns describe the metrics and their respective odds ratios related to the projects for each project we consider only the metrics that do not have collinearity among them like in rq1 cells in gray represent the statistical significance in addition we use the ↑ symbol to indicate a riskincreasing effect and the ↓ symbol otherwise we analyze the riskincreasing or decreasing effect of each metric by considering only the statistically significant cases riskincreasing effect we observe that the metrics test presence changed lines and modified files from forward engineering from and percentage of buggy commits from present a riskincreasing tendency note that only the f2 factor obtains at least one metric having a effect in all projects analyzed in particular the cl metric obtains a riskincreasing effect in all cases among all the metrics analyzed in our study cl reaches the highest effect in seven of the eight projects reaching an odds ratio up to 669 in springboot such fact indicates that each unit of the cl metric increases the odds of a commit being buggy by a factor of 167 up to 669 similarly the metrics pbc mf and tp also present a riskincreasing effect but only in four projects this high number of riskincreasing effects obtained by tp introduces some questions concerning code reviewers that prefer contributions containing tests 1 in the next section we discuss some issues that may lead the tp to obtain this tendency regarding the fep metric it presents a riskincreasing effect in three out of the four projects finally two metrics mcl and nc present only one statistically significant riskincreasing effect which is not enough to characterize a tendency riskdecreasing effect differently from the previous metrics the median of modified files from technical contribution norms management from nature of commits age from project establishment and commit ownership from ownership level present a riskdecreasing tendency the age metric reaches the highest riskdecreasing effect in four out of the six projects in which it is significant it presents an odds ratio of 018 in the bazel project which means that each unit of age decreases the odds of a commit being buggy by a factor of 018 in this project similarly to the age metric the co metric also obtains significant riskdecreasing effect in four out of six projects although this metric presents a riskdecreasing tendency it reaches the highest riskincreasing effect in rxjava we discuss in more detail such case in section iv by analyzing the mmf and mp metrics we note that they present a riskdecreasing effect in all the three projects where each obtain statistical significance the file experience median of social distance and median of ownership metrics present a riskdecreasing effect in two out of the three projects they reached statistical significance however each of these also present one statistically significant riskincreasing effect finally the rp metric obtain a statistical significance only in two projects presenting a riskdecreasing effect due to the small amount of significant cases the fexp msd mo and metrics do not present a tendency towards a riskdecreasing effect when we analyze the risk of the metrics in terms of the technical and social factors we observe that most of the metrics that compose the f2 factor as well as f4 present a tendency towards a riskincreasing effect on the other hand most of the metrics that compose the f5 f6 and f8 factors show a riskdecreasing tendency the developers habit and commit bugginess factors present a riskincreasing tendency on the other hand project establishment ownership level and social influence on contributions present a riskdecreasing tendency iv discussion the contradictory effects of experience metrics regarding the developers experience we observe that two metrics reach a medium and small negative magnitude in the springboot and signalandroid projects respectively on the other hand the same metrics reach a small positive magnitude in the netty and rxjava such contradiction reinforces the results discussed by previous studies 5 6 13 14 eyolfson et al 5 provide evidence from two opensource projects that more experienced developers are less likely to introduce bugs on the other hand prior work 6 13 explains that more experienced developers are more likely to introduce bugs due to the complexity of their tasks thus to understand why the effects of the experience factor is contradictory we further investigate the relation of this factor with the complexity of the changes performed by the developers in particular we investigate whether more experienced developers perform more complex changes to do so we use the spearman ρ rank 35 technique to evaluate if there is a correlation between the developers experience metrics and the complexity of their commits we perform our investigation in the springboot and rxjava projects since two experience metrics present opposite effects in these projects we use the classification defined by cohen 34 to determine the strength of the correlations between these two metrics and the commits complexity in the springboot the two experience metrics present only negative correlations ranging from 021 up to 053 such result suggests that more experienced developers usually perform less complex changes in the springboot such finding may be an indication why more experienced developers introduce fewer bugs in this project on the other hand the same two experience metrics presented positive correlations ranging from 027 up to 045 such result indicates that more experienced developers usually perform more complex changes in the rxjava such finding may be an indication why more experienced developers introduce more bugs in this project even though these results shed light in the understanding about why experience metrics presented contradictory effects on commit bugginess it is still necessary further analysis in order to obtain relevant conclusions that will be investigated in future works the riskincreasing effect of the tp metric previous work 1 18 show that code reviewers prefer contributions that contain tests aiming at improving the software quality however results from rq2 show that the percentage of developers commits that contain tests has a riskincreasing tendency on commit bugginess this finding sounds contradictory to the assumption that testing practices would improve the software quality thus to better understand the reason behind this tendency we further investigate the relation of the tp metric with the complexity of the changes performed by developers our intuition is that this metric may have a riskincreasing effect if the developers who constantly write tests in their commits also perform more complex changes similarly to the previous discussion we use the spearman ρ rank correlation to evaluate the relation between the tp metric and the complexity of their commits we perform our investigation by using the netty springboot okhttp and elasticsearch projects since the tp metric has a riskincreasing effect in these projects springboot okhttp and elasticsearch present positive correlations ranging from 015 up to 042 however the netty project presents a medium negative correlation of 036 hence despite the different behaviour in one project we find evidence indicating that the tp metric is a riskincreasing factor due to the complexity of developers commits commit ownership rxjava and elasticsearch the results of the rq2 show that the co metric has a tendency to riskdecreasing effects on commit bugginess as previously discussed 8 12 14 however the co metric presents a riskincreasing effect in the rxjava project reaching an increase in the odds of a commit being buggy by a factor of 213 this effect may be explained by a singularity in the rxjava project in this project only two developers were responsible for 856 of the bugintroducing changes reported by szz indeed we observe that these developers are the most active ones in the project moreover while the median of the co metric for the remaining developers involved in the project is 023 these two most active developers presented values equals to 070 and 064 such fact shows that the developers responsible for the vast majority of bugintroducing changes in rxjava work mostly on their own code such behavior may explain why the co metric is a riskincreasing factor in the rxjava project a similar behavior is observed in the elasticsearch project where the top 10 contributors are responsible for 75 of the bugintroducing changes since the elasticsearch has almost ten times the size and five times more developers than the rxjava we can see that the pattern holds for bigger projects this result suggests that the riskdecreasing tendency obtained by the co metric in the vast majority of the projects may not hold to projects where a few developers are responsible for most of the bugintroducing commits and also work mostly on their own code reengineering and bugs bavota et al 33 state that several kinds of refactoring operations tend to introduce bugs very often in our study we also analyze the impact of refactoring operations ie reengineering commits on commit bugginess results show that the rp metric presents a riskdecreasing effect in elasticsearch and netty such result suggests that the more focused a developer is on refactoring operations the less likely that his commits introduce bugs in these two projects although our work does not deal with specific kinds of refactorings our finding suggests that general refactoring operations decreases commit bugginess which contradicts the finding of bavota et al 33 v threats to validity construct validity the set of technical and social factors analyzed in our study may not fully represent the reasons that may lead developers to introduce bugs to mitigate this threat we selected factors that were analyzed by previous studies involving investigations on opensource environments 1 3 we considered the perceptions of code reviewers 18 22 to define the metrics related to technical contribution norms nonetheless we cannot guarantee that the community of the analyzed projects agrees with such norms prior work 21 found that 338 of the bug reports from five opensource projects were misclassified ie a feature is requested instead of a bug reported we mitigated this threat by performing a manual validation in all the bug reports collected another threat is related to correctly identify the commits that fixed bugs to mitigate this threat we used a github functionality to identify bugfix commits internal validity we rely on the szz approach to locate the bugintroducing changes although szz has been widely used to locate these changes 28 it presents high false positive and false negative rates to mitigate this threat we also performed a manual validation on a sample of 922 bugintroducing changes reported by szz this validation resulted in an accuracy of 65 for our szz implementation however the false negatives were not included in the manual validation because of the high effort needed to validate such cases external validity regarding the generality of our findings we selected only projects in which the primary language is java although we have analyzed eight projects with different sizes developers and domains our results might not hold to other projects of different primary languages vi related work some previous studies focus on the relation between quality measures and commit bugginess śliwerski et al 2 presented an approach to automatically locate fixinducing commits they found that buggy commits are roughly three times larger than other commits correlations between developer characteristics and commit bugginess were previously investigated by eyolfson et al 5 the authors found that developers who commit on a daily basis write less buggy commits while developers who commit as their dayjob are more likely to produce bugs also eyolfson et al 5 suggested the existence of a correlation between developer experience and commit bugginess posnett et al 10 presented a work on ecological measures of focus in software development and their relation with bugginess the authors defined two measures of focus and found that more focused developers introduce fewer bugs than less focused ones in contrast files that receive narrowly focused activity are more likely to contain bugs than other files rahman devanbu 14 analyzed four opensource projects and found that high levels of ownership are associated with a lower bug introduction rate moreover the authors found that specialized experience is consistently associated with buggy code while general experience is not similar findings on the ownership factor were presented in the work of bird et al 8 thongtanunam et al 12 showed that there is a relationship between ownership and code review in addition the proportion of reviewers without expertise shares a strong relation with commit bugginess tufano et al 13 presented an empirical study on developerrelated factors their results show that commit coherence developer experience and past interfering changes are associated with commit bugginess mockus 6 investigated the organizational factor relating to the presence of defects in software the author found that recent departures from an organization and distributed development are related with commit bugginess bernardi et al 7 studied the influence of developer communication on commit bugginess finding that developers who introduce bugs have a higher social importance and communicate less kamei et al 11 performed a study on defect prediction for justintime quality assurance the authors employed five dimensions to predict the occurrence of defects diffusion size purpose history and experience their results show that the number of files and whether or not a commit fixes a defect are related to an increase in the odds of a commit being buggy those studies 5 8 10 13 evaluated the relation between the factors discussed above and commit bugginess in a more limited way by considering only proprietary projects 6 8 projects that do not adopt modern code review practices 11 13 or a reduced number of factors as well as characteristics to represent them 5 8 10 12 our study differs from prior work by providing a more extensive study on the relation between technical social factors and the introduction of bugs while prior work considers only specific factors 5 7 8 10 12 we consider a comprehensive set of multiple technical and social factors characterized by a large set of metrics moreover unlike prior work 5 7 8 12 we do not only analyze the effects of the metrics in isolation but also analyze their effects grouped as factors that represent distinct aspects of software development finally while prior work conducts their analyses at different granularity levels such as developer 7 source file 8 week batches 6 we conduct our analyses at the commit level taking into account the historical aspects of software development vii conclusion this paper investigated the relation between different technical social factors and the likelihood of developers to introduce bugs we analyzed a total of 6 537 bug reports and 10 674 bugintroducing changes from eight opensource java projects hosted on github to understand which factors may be related to the introduction of bugs we analyzed seven different technical and social factors first we investigated how buggy commits differ from clean commits in terms of these factors then we evaluated how strong is the difference between buggy and clean commits finally we evaluated the effect of each factor on commit bugginess when considering the presence of multiple factors our findings show that both technical and social factors are able to discriminate between buggy and clean commits technical factors are more determining to differentiate buggy commits from clean commits the developers habits of not following technical contribution norms and the developers commit bugginess are associated with an increase on the likelihood of a new commit being buggy and finally the projects establishment the ownership level of developers commit and the social influence are related to a lower chance of introducing bugs we believe that these findings benefit project managers and code reviewers since they may want to carefully verify contributions from developers that present factors related to commit bugginess as future work we intend to asses the importance of contributions outside an analyzed project to better understand developers experience and interactions in such a complex social environment that github is moreover we intend to expand our work on commit bugginess to analyze a wider amount of technical and social factors

as collaborative coding environments make it easier to contribute to software projects the number of developers involved in these projects keeps increasing this increase makes it more difficult for code reviewers to deal with buggy contributions collaborative environments like github provide a rich source of data on developers contributions such data can be used to extract information about developers regarding technical eg their experience and social eg their interactions factors recent studies analyzed the influence of these factors on different activities of software development however there is still room for improvement on the relation between these factors and the introduction of bugs we present a broader study including 8 projects from different domains and 6537 bug reports on relating five technical three social factors and the introduction of bugs the results indicate that technical and social factors can discriminate between buggy and clean commits but the technical factors are more determining than social ones particularly the developers habits of not following technical contribution norms and the developers commit bugginess are associated with an increase on commit bugginess on the other hand projects establishment ownership level of developers commit and social influence are related to a lower chance of introducing bugs

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introduction colorectal cancer is the third most commonly diagnosed cancer and the second leading cause of cancer mortality among men and women in the united states 1 crc incidence and mortality trends have shown significant decreases in the past 10 years for both men and women in the us this trend however is not replicated for the hispanic population for both crc incidence and mortality rates remain stable some of this may be attributed to the lower crc screening rates of hispanics hispanics are significantly less likely to have a recent crc screening test than nonhispanic whites among hispanic subgroups crc screening rates are lowest among mexicanamericans 2 the lack of screening is especially problematic in that screening can result in the detection of early stage crc which often can be treated successfully and result in decreased morbidity and mortality 3 further removal of adenomatous polyps before they become cancerous can reduce crc incidence and mortality 4 there are many impediments to crc screening for hispanic individuals an integrative review of barriers to screening identified a number of factors that were associated with low screening levels these included limited english proficiency low literacy and educational level and lack of provider recommendations 5 the authors of the review concluded that more studies using culturally appropriate and targeted approaches to educate hispanics about crc screening and studies that foster provider training are needed a further barrier to crc screening is rurality individuals who live in rural settings are less likely to obtain crc screening than individuals residing in urban settings 6 one of 23 community network program centers in the us the center for community health promotion of fred hutchinson cancer research center is located in a rural agricultural area of washington state cchp with the participation of its community advisory board designed and implemented a culturally appropriate educational and behavioral intervention to increase the use of crc screening by hispanics it did so in a strategic manner that was focused on making the most efficient use of existing resources in the region the approach used by the cchp is communitybased participatory research where a partnership is formed between the community and academic researchers the cab participates in the design and implementation of research studies and initiatives that seek to reduce disparities further cchp staff have developed partnerships with other community organizations to address the disparities in cancer experienced by residents of this rural area this project began because crc screening is of high importance to people in the area based on findings from two town hall forums conducted by the cchp in april 2011 community members reported being most concerned about crc compared to other cancer sites as part of this cbpr project with the community we attempted to assist the community in addressing that problem the purpose of this paper is to describe the implementation and outcomes of an innovative strategy to increase education and participation in the early detection of crc methods setting the setting for this project is a rural three county region of washington state the counties comprise an area of 7337 square miles and lie east of the cascade mountain range the area is primarily agricultural and grows fruit and vegetable crops that are distributed throughout the us many of the towns in the area are majority minority towns and overall the area is 67 hispanic 7 according to data from the pew hispanic center most of the hispanic population in washington state is of mexican origin as opposed to other latin american countries 8 intervention the community guide to community preventive services recommends interventions such as client reminders small media oneonone education and reducing structural barriers as clientoriented interventions to increase crc screening to address crc screening among the hispanic population we used a fourpronged approach which combined these strategies 1 we sought to increase awareness of the importance of crc screening 2 we educated the population about obtaining crc screening through oneonone education and small media 3 we influenced behavior and reduced structural barriers by disseminating free fecal occult blood test kits to ageeligible individuals and 4 we followedup on abnormal fobt results each approach is described below awarenessour preliminary data from focus groups and small instructional encounters indicated that many hispanics were unaware of crc or the need for crc screening to foster awareness we purchased a giant inflatable colon to attract peoples interest this walkthrough replica of the human colon is 10 feet high 12 feet wide and 20 feet long and contains simulated healthy colon tissue polyps early stage crc and advanced crc six display signs inside the colon explain the progression of cancer from normal tissue to advanced stage cancer and highlight the importance of screening and early detection of crc signs were created in english and spanish the colon was named casper in a community naming contest and was displayed at 47 community events including health fairs throughout communities in the region between march 1 and october 13 2012 education of the populationwe used a participatory strategy to educate the population cchp promotores led tours through the inflatable colon pointing out the progression of crc we invited adult community members 18 years of age and older who attended community events where the inflatable colon was presented to complete anonymous prepost pencil and paper questionnaires in their language of choice cchp promotores were available to help read questionnaires to participants who needed assistance participants were given a prenumbered packet if they were interested in participating they filled out the prequestionnaire before entering the colon handed it to a staff member and then filled out the postquestionnaire after exiting the colon when they returned the postquestionnaire they were given a water bottle as an incentive and were offered printed materials about colorectal cancer behaviorto reduce structural barriers such as reducing time and distance between service delivery and the target population and increase screening behavior we purchased 300 fobt kits and distributed them following a tour of the inflatable colon on the inflatable colon postquestionnaire participants were asked if they were 50 years of age or older and if they were interested in receiving a free fobt kit because this was a population with limited health literacy the fobt instructions were recreated using less text and more pictures they were also translated into spanish fobt kits included a preaddressed and stamped envelope to a local hospital individuals who completed the fobt kits could return them in the supplied envelope to the local hospital for analysis once the local hospital analyzed the fobt they provided the results by participant number to the cchp office we tracked the completion of the fobt kits monitored the outcome and followed up with participants to provide results followupcchp promotores followed up with a phone call to participants to let them know their fobt results if the results were normal the screening guidelines were reviewed with the participant and they were encouraged to followup with their doctor to discuss future screening if the results were positive the cchp promotor explained that it did not mean that they had cancer and they advised the participants to followup with their doctor to complete further testing if participants indicated they did not have a doctor or health insurance they were referred to the patient navigator at the local hospital for assistance with followup we collaborated with local hospitals clinics and the regional breast cervical and colon health program to generate the list of providers who would provide lowcost or free colonoscopies for any participant in our project who had a positive fobt result the protocol as well as promotional flyers participant consent forms fobt instructions and all questionnaires for this intervention were approved by fhcrc institutional review board study measure preand posttests were administered to measure participants familiarity with crc and crc screening past screening behavior likelihood to be screened access to health care likelihood to talk to significant others about crc before and after walking through the inflatable colon demographic variables collected on pretest included gender age education raceethnicity whether they had health insurance and whether they had a regular health clinic and physician awareness of screening was assessed by pretest responses to yesno questions where respondents were asked if they ever talked to their doctor about crc and if their doctor ever recommended they have a fobt sigmoidoscopy or colonoscopy on the posttest we asked respondents how likely they were to talk to their doctor about crc after walking through the inflatable colon familiarity with crc and screening was assessed by five yesno questions at pretest and posttest these questions asked the respondents if they knew what a colon polyp was what crc was what a cancer screening test was what the different types of screening tests available for crc were and whether patients could survive crc if it was found early and removed for intention to be screened we asked respondents at pretest and posttest how likely it was that they would be screened for crc response categories were not likely somewhat likely and very likely on the pretest we also asked respondents if they had ever had a fobt sigmoidoscopy or colonoscopy analysis we examined descriptive statistics of participants using frequencies and proportions the overall proportion of participants answering correctly for each of the 5 questions is shown for preand posttest by gender ethnicity and age in table 2 mcnemars test for paired binary data 910 was used to determine whether there were significant differences in the distribution of the percentage of correct participant response to questions about crc and related items from preto posttest we also used multiplelogistic regression to identify participant characteristics that were associated with being very likely or somewhat likely to get screened at posttest in this analysis very likely and somewhat likely were coded as one and not likely as zero participant characteristics were coded with the reference group being zero and the alternative group coded as one in the unadjusted models we estimated odd ratios using the logit formula logit β 0 β 1 x 1 where p is the probability of being very likely or somewhat likely to get screened using the logistic regression model we estimated the log odds of any selfreported likelihood of getting screened with only one participant characteristic in the adjusted logistic regression models we simply add more participant characteristics to the model to estimate coefficients of y analyses were performed using stata 120 for microsoft windows and the r programming language 11 for table 3 we used a twostep adjustment where in the first adjustment step we only included demographic information in our model in the second step we included the demographic information but also access to care variables all statistical tests were performed with an alpha set at 005 and were two tailed results in the seven months of intervention approximately 35004000 people walked through the inflatable colon 958 completed pretest and 947 completed both preand posttest questionnaires those 947 sets of prepost tests were used for the current analysis characteristics of the 947 participants are presented in table 1 the majority of participants were hispanic and female of the four age categories the majority of participants were 50 years old or older approximately half of the participants had less than a high school education we examined familiarity with crc for all participants as well as familiarity specific to those who were 50 years of age and older there was little awareness of crc screening at pretest there was a significant change in familiarity with crc from no at pretest to yes at posttest for all questions asked when examining familiarity with crc among those aged 50 and older the significant relationships prevailed for all but one question this is likely due to a large proportion of correct answers on the pretest only 156 of respondents had ever talked to their physician about crc and only 168 of respondents reported that their physician had ever recommended that they have any kind of crc screening test respondents were able to identify crc screening methodologies at the posttest something that was only sporadically done on the pretest uniformly the change in familiarity was significant at the 001 level for all questions except for one when examined among participants 50 and older we observed an increase in participants intention to be screened the proportions of respondents who shifted from not likely to somewhat likely or very likely increased significantly for all ages in table 3 we present unadjusted and adjusted odds ratios for participant characteristics associated with posttest likelihood intention to be screened in the unadjusted model being 50 years or older ethnicity education and having a regular physician were associated with intention to have a crc screening test after walking through the inflatable colon in the partially adjusted model being 50 years or older ethnicity and having a regular physician were associated with intention to be screened these associations remained in the fully adjusted models for each of the same categories although with slightly different estimates of the 300 fobt kits distributed to participants 226 were returned of the 226 returned kits six were read as abnormal and one was determined to be unreadable discussion in this study we demonstrated that hispanics who learn about crc can be encouraged to take action toward crc screening using a giant inflatable colon to foster awareness about crc approximately 35004000 individuals received crc information between march and october of 2012 in three rural counties of wa state these counties have high hispanic population proportions as a result of touring the inflatable colon familiarity with crc improved significantly as did intention to obtain screening we supplemented this intervention by providing free fobt kits to a sample of participants who toured the inflatable colon the inflatable colon generated a great deal of attention and interest installed at community events such as outdoor health fairs throughout the region the inflatable colon could be seen from great distances and attendees were eager to see it the inflatable colon was the source of a number of local news stories and received coverage by newspapers and radio stations as a result of the inflatable colon tours crc became a conversational topic among many residents of the community this is supported by the change in responses from pretest to posttest about the likelihood of talking to significant others about crc in addition cchp staff received an increase in the number of requests from organizations who had heard about the inflatable colon or seen it at a community event and were interested in bringing it to their local community the change in familiarity was impressive however in itself it does not speak to behavior change nevertheless the response rate to the distribution of free fobt kits was surprising especially among minority populations such as hispanics who are often noted as facing barriers to screening 5 12 13 14 15 other studies have distributed free fobt kits through mail 16 17 18 clinic visits 19 20 21 22 23 community retail stores 2425 and through pharmacies 2627 none experienced response rates as high as those seen in this study direct mailing yielded anywhere from 28 to 48 participation rate while clinic visits yielded between 48 and 69 fobt return rates for studies that distributed kits via community retail stores and pharmacies were lower the associations with ever having been screened for crc were noteworthy ever screened was associated with age ethnicity having a physician having a clinic and having health insurance the lack of access to a regular physician clinic or health insurance are structural barriers faced by many hispanics 52829 although the association of these barriers with intention to be screened was limited to having a regular physician we were unable to followup and verify the screening behavior of the majority of those who intended to be screened we attribute the success of the response to our fobt screening to a number of factors first we increased awareness of the problem in the area a trip through the inflatable colon showed individuals that polyps that are not removed can develop into crc and that advanced crc can metastasize to other parts of the body other studies also have found that increasing awareness is important in generating action 30 31 32 33 second the provision of the fobt and its analysis were free preventing a major burden of screening that is cost the safetynet clinics that provide free or reduced cost screening often require the completion of documents and that the resident provide proof of income andor citizenship status finally as a result of this and other cbpr projects we have longterm trusting relationships in this area with communitybased organizations and community members which facilitates recruitment and participation in this type of educational intervention limitations this study has some limitations we did not conduct a formal count of people who walked through the inflatable colon at every event although we have information on intention to be screened questionnaires were anonymous thus we cannot determine what percentage of respondents 50 and older followedup by obtaining crc screening after walking through the inflatable colon it was expected that after touring through the inflatable colon participants would have increased awareness of crc the prepost questionnaire responses show each participants increased familiarity with crc but are not an indicator of their ability to retain the information the fobt kit was only distributed to a sample of participant and thus cannot be generalized to the entire population further research is needed to associate followup with crc screening after touring the inflatable colon conclusions the use of an inflatable walkthrough colon appears to be an innovative way to attract people to learn about crc and crc screening modalities there were significant changes in participants familiarity with crc and likelihood to get screened furthermore the response to our distribution of fobt kits indicates that if given the opportunity for education and access to services this population will comply with crc screening this is especially important for racial and ethnic minority populations and people of low socioeconomic status who typically lack health insurance or are underinsured and therefore find it difficult to obtain even basic health care services

hispanics are an underserved population in terms of colorectal cancer crc crc is the second leading cause of cancer incidence among hispanic men and women and hispanics have lower screening rates than nonhispanic whites the overall purpose of this project was to provide crc information education and fecal occult blood test fobt kits to hispanics in a rural threecounty region of washington state we held a series of 47 community health fair events that incorporated the use of a giant inflatable walkthrough colon model with physical depictions of healthy tissue polyps and crc we used a prepostdesign to look for changes in familiarity with crc before and after walking through the colon among adults 18 and older n947 mcnemars test analysis indicated significant differences in the distribution of the percentage of correct participant responses to crcrelated questions from preto posttest after an educational tour of the colon results from logistic regression analysis identified multiple participant characteristics associated with selfreported likelihood of being screened for crc in the three months following posttest we distributed 300 free fobt kits to be analyzed at no charge to the enduser to attendees aged 50 and older who toured the inflatable colon 226 fobt kits 753 were returned for analysis the use of the inflatable colon was an innovative way to attract people to learn about crc and crc screening modalities furthermore the response to our distribution of fobt kits indicates that if given the opportunity for education and access to services this underserved population will comply with crc screening

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theres a stranger in my bed theres a pounding in my head glitter all over the room pink flamingos in the pool i smell like a minibar djs passed out in the yard barbies on the barbeque is this a hickey or a bruise last friday night popular media representations of sexuality demonstrate the pervasiveness of a sexual hookup culture among emerging adults the themes of books plots of movies and television shows and lyrics of numerous songs all demonstrate a permissive sexuality among consumers as an example the lyrics above from the charttopping pop song last friday night by singerϫsongwriter katy perry highlight someones friday night partying presumably including casual sex alcohol and a piecemeal memory of the nights events research on media portrayals of sexual behavior has documented this pattern as well in a 2005 kaiser family foundation report about sex on television media was highlighted as the primary basis for emerging adults opinions about sex consistent with their result of 77 of primetime television programs containing some sexual content in terms of a more permissive uncommitted sexual content 20 of sexual intercourse cases involved characters who knew each other but were not in a relationship and another 15 involved characters having sex after just meeting other studies have shown that college students believe their peers are substantially more sexually permissive than was actually the case these incorrect beliefs of peer sexual norms are in part influenced by students perceptions of media and the influence of media on peers popular culture is simultaneously representing aspects of actual contemporary sexual behavior and providing sexual scripts for emerging adults in the current review we examine and explore these patterns in sexual hookups hooking upbrief uncommitted sexual encounters among individuals who are not romantic partners or dating each otherhas taken root within the sociocultural milieu of adolescents emerging adults and men and women throughout the western world over the past 60 years the prioritization of traditional forms of courting and pursuing romantic relationships has shifted to more casual hookups among heterosexual emerging adults of both sexes hookups have become culturally normative operationalizing hookups hookups may include any sexual behavior in a seemingly uncommitted context nearly all hookups involve kissing 98 of undergraduate respondents in one study reported kissing within a hookup other behaviors are less ubiquitous in another study a combined 81 of undergraduate respondents engaged in some form of hookup behavior with 58 having engaged in sexual touching above the waist and 53 below the waist 36 performed oral sex 35 received oral sex and 34 engaged in sexual intercourse in the context of a hookup research has found minimal gender differences in terms of hookup behaviors the term hookup focuses on the uncommitted nature of a sexual encounter rather than focus on what behaviors count the ambiguity of this term may allow individuals to adaptively manipulate others perceptions of their sexual behavior operational definitions of hookups differ among researchers hookups may be characterized as a form of casual sex or uncommitted sexual encounter hatfield hutchison bensman young and rapson define casual sex as outside of a formal relationship without a traditional reason for doing so paul mcmanus and hayes omitted the possibility of hooking up with previous partners or friends by defining a hookup as a sexual encounter usually only lasting one night between two people who are strangers or brief acquaintances some physical interaction is typical but may or may not include sexual intercourse using a broad situational definition garcia and reiber told participants a hookup is a sexual encounter between people who are not dating or in a relationship and where a more traditional romantic relationship is not an explicit condition of the encounter lewis granato blayney lostutter and kilmer used a more behaviorally specific definition in which hooking up was defined as a event where you were physically intimate with someone whom you were not dating or in a romantic relationship with at the time and in which you understood there was no mutual expectation of a romantic commitment glenn and marquardt used an explicitly heteronormative definition for participants a hookup is when a girl and a guy get together for a physical encounter and dont necessarily expect anything further friends with benefits on the surface hookups are slightly different from more protracted mutual exchange arrangements for uncommitted sex like those often referred to with colloquialisms such as friends with benefits booty calls or fuckbuddies in terms of popular public discourse urban dictionary defines fwbs as two friends who have a sexual relationship without being emotionally involved typically two good friends who have casual sex without a monogamous relationship or any kind of commitment and also a safe relationship that mimics a real partnership but is void or greatly lacking jealousy and other such emotions that come with a serious relationship yet popular culture representations suggest fwb partnerships may not truly be void of romantic elements fwb relationships represent a unique variation of hooking up worthy of more research attention which it is beginning to generate in one study 60 of 125 undergraduates reported having a fwb relationship at some point in their lives of those who had engaged in a fwb experience 987 were with an opposite sex partner and 13 with a samesex partner much like in the movie of the same name a common concern of participants describing their fwb relationships was the potential formation of unanticipated romantic feelings at the time of the survey 358 stayed friends but stopped having sex with their most recent fwb partner 283 were maintaining an fwb relationship 259 ended their relationship or friendship and 98 initiated a romantic relationship because these situations represent a greater entanglement of friendship trust and emotional comfort fwbs are distinct from notions of hooking up in some aspects namely hookup scenarios do not implicitly include a friendship relationship component as a condition hooking up as contemporary casual sex there are also a large number of colloquial expressions used to describe uncommitted sexual behavior including labels like no strings attached sex casual encounters and onenight stands it is important to explore whether and in what context these phrases are really interchangeable with hookups hookups are different from infidelity situations in which an individual engages in sex with an extrarelational partner but is still functionally committed to the relationship partner however some sexual subcultures with open relationships actually allow extrarelationship casual sex without considering it to be a betrayal for instance the frequency of open relationships among gay men where extrarelational casual sex is permissible has been estimated as high as 60 in a sample of 2027 gay men from australia although 15 had no sexual relationship at time of the survey 30 of men had a regular monogamous relationship partner 23 had a casual sex partner and 32 had both a regular partner and casual sex in these cases some extrapair encounters may constitute uncommitted hookups albeit not among singles across gender ethnicity or sexual orientation nearly all adult americans experience sexual activity including sex beyond the context of a marital union it is important to note that uncommitted sex and onenight stands have been studied outside the current hookup culture frame uncommitted sexual encounters became a topic of particular scientific interest beginning in the mid 20th century and especially during the sexual liberation period of the 1960s and 1970s attention to causal sexual encounters among men who have sex with men also emerged as an area of study during the aids epidemic in the 1980s until today yet this larger casual sex literature has remained largely disjointed from investigations of hookups research on brief uncommitted sexual behaviors outside of traditional relationships extends well beyond heterosexual collegiate populations including samesex sexual behaviors among men who have sex with men these complementary literatures and approaches should be integrated into the future study of hookup behavior because the study of human sexuality must consider the vast range of variation and potential in human sexual behaviors a case in point findings from the national survey of sexual health and behavior identified a much higher rate of american men and women who had ever engaged in samesex sexual behavior compared to those who identify with a homosexual orientation this raises an important but as of yet unanswered question if a proportion of heterosexual americans have at some point engaged in at least one samesex sexual encounter is the context of such a scenario a hookup although speculative it seems most probable that many such encounters are sexual experiments and uncommitted but investigations of how this relates to the larger hookup culture are sorely lacking frequency of hooking up a vast majority of todays young adults from a wide range of college student populations studied so far report some personal casual sexual experience the most recent data suggest that between 60 and 80 of north american college students have had some sort of hookup experience this is consistent with the view of emerging adulthood 3 sexual hookup culture aq 5 tapraid5zrpgenpzrpgenpzrp00212zrp2214d12z xppws sϭ1 32112 518 art 20120423 as a period of developmental transition exploring and internalizing sexuality and romantic intimacy now including hookups although much of the current research has been done on college campuses among younger adolescents 70 of sexually active 1221 year olds reported having had uncommitted sex within the last year similarly in a sample of seventh ninth and 11th graders 32 of participants had experienced sexual intercourse and 61 of sexually experienced teenagers reported a sexual encounter outside the context of a dating relationship this represents approximately one fifth of the entire sample hookup venues among college students hookups have been reported in a variety of college settings one study of students perceptions of hookups reported that 67 occur at parties 57 at dormitories or fraternity houses 10 at bars and clubs 4 in cars and 35 at any unspecified available place in addition to college campus locations spring break and holidays have been a time many individuals particularly emerging adults will purposely plan to experiment or engage in uncommitted sexual activity and other highrisk behaviors in a study of canadian college students on spring break of those explicitly planning to participate in casual sex 61 of men and 34 of women engaged in intercourse within a day of meeting a partner this is echoed in another more recent report where regardless of relationship status approximately 30 of participants had sex with someone they met on spring break such settings may help facilitate a preexisting desire for hookups more generally in a sample of sexually experienced men and women participants indicated a variety of settings where they met someone with whom they had casual sex 70 at a party 56 at a singles bar 43 while away on vacation 28 at a dance 7 while away on business and 5 on a blind date in addition to sharing common social venues with heterosexuals gay men and other men who have sex with men have an expanded array of venues in which hookups may occur research specifically sampling gay men and other men who have sex with men have similarly found bars to be common places for gay men to meet socialize and find others for casual sexual encounters although uncommitted sex among gay men occurs in a variety of locations antigay prejudice and structural heterosexism can limit the availability of supportive and safe options for connecting with other men consequently more anonymous sometimes public spaces have been an alternative for some gay men in a sample of 508 gay and bisexual men in college nearly one third admitted to meeting partners in anonymous places public cruising areas internet cruising networks and bathhouses are somewhat popular venues for explicitly initiating uncommitted sex among men who have sex with men these are not findings that seem to be prevalent among lesbians and women who have sex with women or among heterosexual hookups theoretical frameworks for hookup research an interdisciplinary biopsychosocial model can synthesize traditionally disconnected theoretical perspectives and provide a more holistic understanding of hookup culture hatfield et al state that while many scholars emphasize cultural factors and others emphasize evolutionary factors increasingly most take a cultural and biopsychosocial approachpointing out that it is the interaction of culture social context personal experience and biological factors that shape young peoples attitudes and willingness to participate in casual sexual encounters which of these factors prove to be most important depends on culture personality gender and social context some empirical studies of hookup behavior have also advocated multifactorial approaches evolutionary and social models often generate parallel hypotheses about uncommitted sex although each addresses a different level of analysis using two midlevel theories fisher et al explained that parental investment theory is an example of an ultimate level of explanation while social role theory is an example of a proximate level although each leads to the same prediction they argued that evolution may be most helpful in exploring the reproductive motive and sexual scripts may be useful in exploring the cultural discourse agenda that is evolutionary biology influences why emerging adults engage in uncommitted sex and the way young men and women react to these encounters at the same time social roles and sexual scripts influence how emerging adults navigate their desires in a particular sociocultural context for instance that religiosity was related to lower frequency of engaging in intercourse during a hookup encounter may be envisioned as an adaptive sociocultural constraint or that high degrees of closeness to peer social networks and peer communication about hookups was associated with more sexual hookups may be considered as a facultative response to adaptively react to peer expectations and local norms it is important to point out that many sociocultural theorists disagree with the idea that culture offers only a proximate level explanation for human sexual behavior however it is not the goal of this review to resolve this debate instead we attempt to articulate better the multitude of factors that shape the rich variety of human sexuality to enhance understanding of uncommitted sex among emerging adults in the next two sections we will introduce both evolutionary and social script views of uncommitted sex to simultaneously consider the influence of each on hookup culture evolution and shortterm sexual behavior human evolutionary behavioral studies attempts to explain sexual behavior by understanding our evolutionary history and how this may influence behavioral patterns in a given environment there are several different midlevel evolutionary or biological 4 garcia reiber massey and merriwether tapraid5zrpgenpzrpgenpzrp00212zrp2214d12z xppws sϭ1 32112 518 art 20120423 theories about the nature of human sexual behavior these theories seek to understand the way evolutionary pressures influence human sexual propensities variation and in some cases sex differences this logic is based on the premise that compared to asexual reproduction sexual reproduction is quite costly sexually reproducing organisms pay many costs including the time energy and resources spent in finding and attracting matestasks that are unnecessary for asexual reproducers offsetting the costs of sexual reproduction in largebodied organisms is the benefit sexual reproduction provides against easy colonization by parasites and pathogens sexual reproduction scrambles up genes creating genotypes that are novel environments and forcing the parasites and pathogens to begin anew in their quest to exploit the host thus largebodied organisms with long lifespans generally benefit evolutionarily from sexual reproduction despite its substantial costs sexual reproduction is characterized by sexesgenerally male and femalewhose evolutionary best interests differ because their potential reproductive rates differ in humans producing a viable offspring from gestation through lactation takes females longer than it takes males the sex with the faster potential reproductive rategenerally malescan benefit by attempting to coopt the reproductive effort of multiple members of the opposite sex however the sex with the slower potential reproductive rategenerally femaleswill be operationally in short supply relative to the sex with the faster potential reproductive rate simply because it takes them longer to complete a reproductive venture according to evolutionary theorists this discrepancy in reproductive rate between the sexes sets up general predictions about sexspecific mating behaviors males are predicted to compete for access to the reproductive potential of the slower sex this generates expectations of psychological and physical adaptations in males that enhance their chances of success including aggression and an array of physical features that would assist them in competing with other males for access to females females are predicted to be choosy concerning their mates because they invest more in each offspring and they stand to lose more if they make a poor reproductive choice relative parental investment costs are thought to be the arbiters of mating behaviors thus in sex role reversed species where males provide a majority of parental support it is females that are then expected to compete more for mates and be more indiscriminate in their mating generally females choose mates on the basis of whatever is most important to the success of the reproductive ventureat the least good genes for the offspring but often for particular resources with which to provision offspring protection andor apparent willingness to assist in parenting because females choose males on the basis of critical features and resources males are expected to compete with other males to acquire and display these features and resources this provides a basic framework with which to begin and in humans we expect complex cognitive processes to be overlaid on it in terms of applying this logic to human sexual behavior and in particular sexual hookups uncommitted sex has most often been interpreted in evolutionary terms as a fitnessenhancing shortterm mating strategy in this viewsexual strategies theorymen prefer as many mates as possible including shortterm sexual encounters that can potentially maximize reproductive output men will attempt to mate with a maximum number of partners consent to sex more quickly than women and provide minimal resources to any but longterm partners only conceding to a longterm relationship for the purposes of enhancing offspring vitality also in this view women are expected to prefer longterm relationships to extract a maximum amount of resources from mates women will engage in shortterm sex when it is typically viewed as an infidelity to obtain better quality genes for offspring that is sexual strategies theory does allow for both men and women to engage in longterm and shortterm sexual behaviors but for sexspecific evolutionary reasons in petersen and hydes thorough metaanalytic review of gender differences in sexuality research men and women are more similar than different in a majority of sexual behaviors the exceptions yielding the greatest effect sizes included mens greater permissiveness toward casual sex behavior and casual sex attitudes this mirrors an earlier review finding that gender differences in attitudes toward casual sex were some of the most pronounced differences of all sexual behaviors in measuring propensities for nonrelational sex a variety of studies conducted within north america have demonstrated that men consistently have higher sociosexuality scores than women research on sociosexuality has suggested individual differences in disposition toward engaging in sexual behavior and exhibitionism with some individuals more permissive and some nonpermissive about sexual frequency individuals with more permissive sociosexuality rate physical attraction as more important than other characteristics in a potential partner several scholars have argued that the degree to which evolution shapes mating behaviors including sociosexuality will be contingent on particular environmental conditions to support the idea that sociosexuality is likely a combination of evolved sexspecific mating strategies and social structural factors in a study of over 200000 participants from 53 nations lippa demonstrated that although consistent sex differences emerged gender equality and economic development tended to predict the magnitude of sex differences in sociosexuality similarly wood and eagly have endorsed a biosocial model for understanding sex differences crossculturally that takes into account multiple levels of analyses including biological constraints alongside social and economic constraints in support of evolved sexual strategies in a crosscultural study of 16288 individuals across 52 nations schmitt et al showed that on average men selfreport a greater desire for sexual partner variety than women regardless of relationship status or sexual orientation using the shortterm seeking measure they reported that in north america relatively more men than women fall into the category of seeking shortterm 5 sexual hookup culture aq 6 tapraid5zrpgenpzrpgenpzrp00212zrp2214d12z xppws sϭ1 32112 518 art 20120423 mates in any way of note using the crosscultural responses of those who are single 793 of men and 640 of women reported seeking a shortterm mate in some way evolutionaryinclined researchers have often used these findings to point to the adaptive nature of sexspecific mating strategies these data demonstrate fairly modest relative sex differences in propensities toward sex beyond a committed relationshipwhich are indeed important to document yet a crosscultural sex difference of 153 in number of single men and single women interested in seeking a shortterm mate does not necessarily reveal discreet sexspecific mating strategies per se this is especially true considering that compared to males the relative risks of sexual behavior are higher for females unintended pregnancy increased transmission of disease and greater susceptibility to sexual violence although there is a reasonable proportional difference between sexes there are still nearly two thirds of unpartnered women interested in uncommitted sex and over one fifth of unpartnered men who are not interested in this activity in short there is significant overlap between the sexes and significant variation within the sexes all things considered the simplest expectation is that evolutionary processes will result in both men and women desiring both sex and pairbonding extrarelational sex is part of the human mating repertoire as is pairbonding individuals have competing sexual and relational motivations at any given time which should be expected to go in one direction or the other depending on an individuals environmental context the popularity of hooking up among both men and women presents a problem for approaching human sexuality purely from the perspective of sexual strategies theory that both men and women are engaging in this behavior at such high rates is not consistent with the model homosexual relationships also presents a quandary for sexual strategies theory although the proportion of gay men in open relationships seems to support the theory the expectation that males should mateguard their partners to prevent sexual infidelity cannot simultaneously coexist with such prevalence of open relationships among gay men several evolutionary scholars have started to question the ability of sexual strategies theory to accurately reflect patterns of shortterm sex in a shifting ecological context and they have proposed alternative evolutionary approaches for instance li and kenrick have pointed to the benefits of using an evolutionary economic model of tradeoffs to understand sex differences in willingness to engage in shortterm sex and sex similarities in prioritization of shortterm partners using biological and crosscultural evidence fisher has argued human possess a dual reproductive strategy of social monogamy and clandestine adultery pedersen et al applied attachment fertility theory and demonstrated relatively few sex differences arguing that predictions from sexual strategies theory are not consistent with their data in their comparison of theoretical models they found that attachment fertility theory posits that shortterm mating and other forms of mating outside of pairbonds are natural byproducts of a suite of attachment and caregiving mechanisms selected for in human evolutionary history to ultimately enable men and women to seek select create and maintain a pairbond pointing to an increasingly coherent picture of the underlying biological and chemical systems involved that generally operate similarly for men and women if humans possess a fairly flexible sexual repertoire yet pairbonding is essential this sets the stage for a conflict between competing motivational drives that are fine tuned to particular environments in accordance with an evolutionary model the simplest most general prediction is that men will be relatively more competitive and sexually eager and that women will be relatively choosier further in accordance with an evolutionary model emphasizing pairbonding both men and women will have competing motivational drives for sexual engagement and pairbond formation this might assume that penetrative sexual intercourse between fertile men and women entails a sizable risk of reproduction for femalesan assumption that simply no longer applies to humans in the 21st century in contemporary industrialized cultures pleasurable sexual behaviors can be divorced from reproduction and used for other purposes including social standing and simple enjoyment among others contraception and reproductive technologies allow women greater control over reproduction but this should not be enough to completely overwrite millions of years of evolutionary pressure to shape certain aspects of mating psychology rather in these contemporary conditions those who use contraception to optimize their reproductive output may well be evolutionarily favored women could for example use contraception to control the timing of pregnancies in ways that maximize the chance of success or ensure parentage by favored males over lesserquality mates and males too may be able to control siring a child and the crossculture expectation of fatherhood thus contraception is simply an additional feature of the environment of reproduction and males and females are expected to attempt to manipulate it in their own favor psychological adaptations that support the choosy female strategy are still evident even when individuals choose to engage in nonreproductive sexual behavior however the ability to divorce sex from reproduction should allow for less discrepancy between males and females in willingness to engage in uncommitted sex and negotiations of both sexual and romantic desires clearly the evolved reproductive motive involves both sexes desiring sex and desiring pairbonds but having different ways of obtaining each and different prioritizations for each sexual scripts and uncommitted sex sexual script theory suggests that our sexual behaviors are dictated by a set of scripts that are used to organize and interpret sexual encounters into understandable conventions scripts particularly gendernormative ones dictate behaviors such as who does what and when in context the most widely produced and promoted cultural sexual scripts are heterosexual in nature and include those focused on male roles for men sex is portrayed as central to male identity men 6 garcia reiber massey and merriwether aq 7 tapraid5zrpgenpzrpgenpzrp00212zrp2214d12z xppws sϭ1 32112 518 art 20120423 prefer nonrelational sex and men are active sexual agents women are portrayed as sexual objects sexually passive compared to men and women act as sexual gatekeepers sexual script theory is generally vague when it comes to origins focusing more on descriptions of scripts wiederman phillips and jhally have argued that scripts are not only sexualized but also gendered with underlying sexual messages being noticeably different for men and women many researchers have favored culture and subculture environment elements such as popular media as the origin of gendered sexual scripts but this does little to explain why the media industry produces these scripts in the first place it is not by accident that consumer behavior can be wellexplained by those products most salient to human survival and reproduction and why messages of love and sex are among the most producible but on their own both the evolutionary perspective and the social scripts perspective have thus far been inadequate in fully unpacking the origin of sexual messages their propagation and their social retention without identifying a primary hierarchal origin it is likely that media is reflecting actual behavioral change in a circular waymedia is a reflection of our evolutionary penchants further exaggerated and supported by the presumption that it is popular images of a polymorphous sexuality that decenters the reproductive motive and focuses instead on sexual pleasure are consistently appearing in popular media in music lyrics for example although opera arias and art songs have contained messages about reproduction and mating for more than 400 years it is contemporary music lyrics where an erotic uncommitted sexuality has predominated some popular portrayals go against the popular trend such as american idol star kelly clarksons billboard hot 100 song i do not hook up released in 2009 cowritten and covered under the title hook up by american singerϫsongwriter katy perry other representations celebrate sexual liberation such as kylie minogues all the lovers and madonnas frequent reversal of male sexual dominance hobbs and gallup performed a content analysis of song lyrics from billboards top ten charts for country pop and r b they found that of 174 different songs in the top ten lists from 2009 92 contained messages about reproduction or mating with the bestselling songs containing more such messages than lesssuccessful songs the ubiquitous presence of these reproductive themes is a reflection of evolved properties in the human psyche where people are voting with their pocket books and listener preferences are driving the lyrics it seems plausible that sexual scripts in popular entertainment media are exaggerated examples of behaviors that are taken to an extreme for the purposes of media sensationalism and activation of core guttural interests conflicting gendered scripts may contribute to mixed perceptions and expectations of hookups in a detailed qualitative study of girls first sexual experiences phillips made the case that conflicting media discourse messages make it difficult for women to navigate sexual initiation the first sexual experiences described by the 30 participants were almost all quite negative girls receive conflicting messages about being a good girl and a pleasing woman but also a together woman a together woman is agentic and experienced such as the character samantha from sex in the city who is sexually assertive and displays a strong almost stereotypically masculine desire discourse many women find the discrepant messages difficult to navigate to be a good girl to be a samantha or to try and be both messages often portray the sexually assertive woman as a woman who has extreme difficulty in being genuine and having a meaningful romantic relationship psychoanalytic analysis views this conflict as the madonnaϫwhore dichotomy where women face challenges in being viewed as both a sexually expressive being and a maternal committed being and at the same time their romantic or sexual partners face challenges with categorizing women as one or the other presumably these same conflicting discourse messages can make it difficult for individuals to psychologically navigate hookups including sexual decisionmaking there seems to be inconsistency in the scripts pertaining to the casualness and emotional investment in causal sexual encounters an example of this disconnect is presented by backstrom armstrong and puentes whose study examined the responses of 43 college women who described their difficulties in their negotiations of cunnilingus such as desiring it in a hookup or not desiring it in a relationship as another example a qualitative study of mens hookup scripts also displayed inconsistency in casualness men easily described stereotypic hookups and fwbs as nonrelational and noncommitted and in an oppositional fashion compared to romantic committed datingesque relationships yet in interviews participants also expressed distinct discomfort with these extrarelational scripts men voiced alternative definitions that highlighted emotional connection and the potential for committed romantic relationships while contrary to nostrings attached hookup discourse these alternative romance and commitmentoriented scripts are not surprising similar discourse messages are present in other aspects of popular media this is consistent with phillipss conclusion that media messages are contradictory in addition to media focused on casual sex emerging adults have simultaneously been fed a disney film diet with romantic relational scripts in which men and women live happily ever after as heterosexual love conquers all it is curious that although purporting to regale the audience with nonrelational sex the previously mentioned films friends with benefits and no strings attached also highlight this in the end couples in both movies actually end up in seemingly monogamous romantic relationships although the evolutionary reproductive motives produce contradictory motivations for both shortterm sex and longterm commitment some media scripts apparently do the same hookups as more than just sex despite the high prevalence of uncommitted sexual behavior emerging adults often have competing nonsexual interests in a study of 681 emerging adults 63 of collegeaged men and 83 of collegeaged women preferred at their current stage of life or development a traditional romantic relationship as opposed to an uncommitted sexual relationship although there is a proportional sex difference note that a substantial majority of both sexes would prefer a romantic relationship despite their particular developmental stage of emerging adulthood in another survey of 500 students 7 sexual hookup culture aq 8 aq 9 tapraid5zrpgenpzrpgenpzrp00212zrp2214d12z xppws sϭ1 32112 518 art 20120423 who all had experiences with hookups 65 of women and 45 of men reported that they hoped their hookup encounter would become a committed relationship with 51 of women and 42 of men reporting that they tried to discuss the possibility of starting a relationship with their hookup partner the gender differences observed are modest and point to the convergence of gender roles in hookup culture even though there are some gender differences it should not be ignored that the curves overlap significantly just as the discourse of hooking up is often in conflict with itself individuals often selfidentify a variety of motivations for hooking up in one investigation of the concomitant motivations for hookups garcia and reiber found that while 89 of young men and women reported that physical gratification was important 54 reported emotional gratification and 51 reported a desire to initiate a romantic relationship there were no sex differences in the responses that a substantial portion of individuals reported emotional and romantic motivations appears to be in apparent conflict with the sexual strategies framework discussed earlier which predicts significant sex differences however this is not in conflict with an evolutionary pairbond hypothesis which suggests that humans desire both sex and romantic intimacy indeed some hookups turn into romantic relationships paik found that individuals in relationships that start as hookups or fwbs report lower average relationship satisfaction however this varied as a function of whether the participants initially wanted a relationship if individuals were open to a serious committed relationship initially relationship satisfaction was just as high as those who did not engage in uncommitted sexual activity prior to starting a relationship the entanglement of more intimate and emotional aspects with sex is something the romantic comedy movies mentioned earlier highlight again in seeming contrast to the sexspecific mating strategies contemporary hookup behavior involves a high degree of female sexual assertiveness for sexual desire and pleasure in another study of selfreported motivations for hooking up which included 118 female firstsemester students 80 indicated sexual desire 58 spontaneous urge 56 perceived attractiveness of the partner 51 intoxication 33 willingness of the partner and 29 desire to feel attractive or desirable contrary to some media messages individuals do not appear to be engaging in truly nostrings attached sex competing interests at multiple levels result in young adults having to negotiate multiple desires and multiple social pressures again the most fruitful explanation is that both men and women have competing sexual and romantic interests with tremendous individual differences in such desires not all sexual subcultures necessarily experience casual sex in the same singles context as such the simultaneous motivations for sex and romance may appear different beyond heterosexual hookups casual sex has been reported to be a normative sexual script among men who have sex with men despite the existence of casual sex and open relationships among gay men there is also a strong desire for romantic and companionate attachment early ethnography by cory described sections of gay culture as being brought together driven by the sensual impulse seeking new forms and new partners for the love of the flesh hoping to find excitement and satisfaction the origins of these prosex scripts have been theorized to be due to a subculture focused on male sexuality another explanation is the social relegation of gay men to the status of deviant limiting access to socially sanctioned relationship scripts however discourse surrounding monogamy in gay relationships does demonstrate simultaneous desires for sexual variety and commitment representing a kaleidoscope of issues about trust love and sexual behavior because samesex relationships are naturally removed from the reproductive motive it may be possible that part of the larger hookup culture is borrowed from sexual subcultures involving greater emphasis on the positive erotic hookup culture and sexual risk the negative consequences of hookups can include emotional and psychological injury sexual violence sexually transmitted infections andor unintended pregnancy despite various health risks in a qualitative study of 71 college students nearly half of participants were unconcerned with contracting a sexually transmitted infection from penetrative intercourse during a hookup and a majority were unconcerned about diseases in hookups that included fellatio or cunnilingus most students reported not considering or realizing their own health risks during hookups particularly those that occurred within their own community such as with someone else on their own college campus compounding disease risks individuals involved in hookups are more likely to have concurrent sexual partners in a sample of 1468 college students among the 429 students who had engaged in oral sex anal sex or vaginal intercourse in their most recent hookup only 466 reported using a condom although in paul et als study conducted nearly a decade earlier of those hookups that included sexual intercourse a higher yet still too low 81 of participants reported using a condom among women in their first semester of college fielder and carey reported that condoms were used for 0 of oral sex hookups and only 69 of vaginal sex hookups healthbased hookup research like this may lead to programs for correcting misperceptions of sexual risk and sexual norms to ultimately restore individual locus of control over sexual behavior reproductive rights and healthy personal decisionmaking prevalence of alcohol and drugs in addition to sexual risktaking in terms of low condom use another issue of concern involving hookups is the high comorbidity with substance use as part of a larger study in a sample of several thousand individuals aged 1525 men and women who had used marijuana or cocaine in the last 12 months were also more likely than nonusers to have had nonmonogamous sex in the past 12 months although an operational definition for these presumably uncommitted partnerships was not discussed more specifically in one study of undergraduate students 33 of those reporting uncommitted sex indicated their motivation was unintentional likely due to alcohol and other drugs in fielder and careys study among 118 firstsemester female college students participants reported that 64 of uncommitted sexual encounters follow alcohol use with a median consumption of 3 alcoholic drinks similarly another study employing a webbased survey found that nearly 61 of undergraduate students used alcohol with an average of 33 alcoholic drinks during their most recent hookup further in a study based on 71 interviews with college students nearly 80 indicated that alcohol was involved in initiating their most recent hookup with 64 attributing the progression and extent of the hookup to alcohol alcohol use has also been associated with type of hookup greatest alcohol use was associated with penetrative sexual hookups less alcohol use with nonpenetrative hookups and least amount of alcohol use among those who did not hookup in one study of men and women who had engaged in an uncommitted sexual encounter that included vaginal anal or oral sex participants reported their intoxication levels 35 were very intoxicated 27 were mildly intoxicated 27 were sober and 9 were extremely intoxicated alcohol and drug use drastically increases the overall risks of sexual activity alcohol may also serve as an excuse purposely consumed as a strategy to protect the self from having to justify hookup behavior later this paints a picture very different from popular representations of alcohol and substance use in hookups which are often handled with a detached air of humor for instance the interactive book hookups hangovers a journal is playfully described by the publisher here to help piece together all the hilarious and humiliating details of last nights party playful promptsincluding where did i wake up and so drunk i cant believe i as well as space to rate your hookups and hangoversmake this guided journal the perfect accessory for the morning after these findings raise several concerns about the occurrence of hookups and the psychological impact such behaviors have on the individuals involved although alcohol and drugs are likely a strong factor it is still largely unclear what role individual differences play in shaping decisions to engage in hookups in a sample of 394 young adults the strongest predictor of hookup behavior was having previously hooked upthose who engaged in penetrative sex hookups were approximately 600 more likely than others to repeat this over the course of a university semester other factors may include media consumption personality and biological predispositions garcia mackillop et al demonstrated an association between the dopamine d4 receptor gene polymorphism and uncommitted sexual activity among 181 young men and young women although genotypic groups in this study did not vary in terms of overall number of sexual partners individuals with a particular risktaking variant of the dopamine receptor d4 gene were shown to have a higher likelihood of having uncommitted sexual encounters however no sex differences were observed this suggests that biological factors that contribute to motivating the different contexts of sexual behavior for both men and women may be fairly sexually monomorphic this may in some cases point to fairly stable individual differences hookup culture and psychological wellbeing the discrepancy between behaviors and desires particularly with respect to socialϫsexual relationships has dramatic implications for physical and mental health despite widespread allure uncommitted sexual behavior has been shown to elicit a pluralistic ignorance response promoting individuals to engage in behaviors regardless of privately feeling uncomfortable with doing so individuals overestimate others comfort with hookups and assign variable meanings to those behaviors misperception of sexual norms is one potential driver for people to behave in ways they do not personally endorse in a replication and extension of lambert et als study reiber and garcia found that 78 of individuals overestimated others comfort with many different sexual behaviors with men particularly overestimating womens actual comfort with a variety of sexual behaviors in hookups hookup scenarios may include feelings of pressure and performance anxiety in paul et als study on hookups 16 of participants felt pressured during their typical hookup in this sample 12 of participants felt out of control when penetrative intercourse was not involved while 22 percent felt out of control when sexual intercourse took place note that this study asked participants about typical hookups and although this was informative for general patterns it does not capture specific factors influencing specific individual scenarios that is it is unclear how one might rate a typical hookup if for instance one instance involved sexual coercion and regret while other hookup experiences before andor after such an event were consenting and more enjoyable in a multiethnic sample of 109 women hookup scripts were compared to rape scripts and even though hookup scripts contained psychological consequences such as shame a majority did not presume sexual assault further in a qualitative study that asked 187 participants to report their feelings after a typical hookup 35 reported feeling regretful or disappointed 27 good or happy 20 satisfied 11 confused 9 proud 7 excited or nervous 5 uncomfortable and 2 desirable or wanted however this same study found that feelings differed during compared to after hookups during a typical hookup 65 of participants reported feeling good aroused or excited 17 desirable or wanted 17 nothing in particular or were focused on the hookup 8 embarrassed or regretful 7 nervous or scared 6 confused and 5 proud just as multiple motivations can be in conflict and multiple discourse messages can be in conflict individuals affective reactions during and after a hookup can be in conflict an individual history of hookup behavior has been associated with a variety of mental health factors in a recent study of 394 young adults followed across a university semester those participants with more depressive symptoms and greater feelings of loneliness who engaged in penetrative sex hookups subsequently reported a reduction in both depressive symptoms and feelings of loneliness at the same time those participants who reported less depressive symptoms and fewer feelings of loneliness who engaged in penetrative sex hookups subsequently reported an increase in both depressive symptoms and feelings of loneliness in another study among 291 9 sexual hookup culture aq 11 tapraid5zrpgenpzrpgenpzrp00212zrp2214d12z xppws sϭ1 32112 518 art 20120423 sexually experienced individuals those who had the most regret after uncommitted sex also had more symptoms of depression than those who had no regret however in the same sample womens but not mens degree of depressive symptoms increased with number of previous sex partners within the last year in the first study to investigate the issue of selfesteem and hookups both men and women who had ever engaged in an uncommitted sexual encounter had lower overall selfesteem scores compared to those without uncommitted sexual experiences the potential causal direction of the relationship between selfesteem and uncommitted sex is yet unclear hookups can result in guilt and negative feelings in a study of 169 sexually experienced men and women surveyed in singles bars when presented with the question i feel guilty or would feel guilty about having sexual intercourse with someone i had just met 32 of men and 72 of women agreed with the statement the percentage of women expressing guilt was more than twice that of men this is consistent with a classic study by clark and hatfield which demonstrated that men are much more likely than women to accept casual sex offers from attractive confederates conley replicated and extended this finding demonstrating that under certain conditions of perceived comfort the gender differences in acceptance of casual sex is diminished in a study of 333 men and 363 women on a college campus in deliberate hookup situations women had more thoughts of worry and vulnerability than men moreover as number of sex partners increased marital thoughts decreased for both sexes qualitative descriptions of hookups reveal relative gender differences in terms of feelings afterward with women displaying more negative reactions than men this is also consistent with earlier work demonstrating a gender difference with women generally identifying more emotional involvement in seemingly low investment sexual encounters than men moreover in a study of 140 firstsemester undergraduates women but not men who had engaged in penetrative intercourse during a hookup showed higher rates of mental distress possibly contributing to findings on gender differences in thoughts of worry in a sample of 507 undergraduate students more women than men leaned toward a relationship outcome following a hookup only 44 of men and 82 of women expected a traditional romantic relationship as an outcome while 29 of men and 429 of women ideally wanted such an outcome it is possible that regret and negative consequences result from individuals attempting to negotiate multiple desires it is likely that a substantial portion of emerging adults today are compelled to publicly engage in hookups while desiring both immediate sexual gratification and more stable romantic attachments not all hookup encounters are necessarily wanted or consensual individuals occasionally consent to engage in a sexual act but do not necessarily want sex in a sample of 178 college students participants noted that a majority of their unwanted sex occurred in the context of hookups 778 during a hookup 139 in an ongoing relationship and 83 on a date similarly in a sample of 761 women students approximately 50 of women reported at least one experience of unwanted sex of those women 70 experienced unwanted sex in the context of a hookup and 57 in the context of a committed romantic relationship even more worrisome a proportion of hookups also involve nonconsensual sex in a study by lewis et al 863 of participants portrayed their most recent hookup experience as one they wanted to have while 76 indicated that their most recent hookup was an experience they did not want to have or to which they were unable to give consent unwanted and nonconsensual sexual encounters are more likely occurring alongside alcohol and substance use hookup regret a number of studies have included measures of regret with respect to hookups and these studies have documented the negative feelings men and women may feel after hookups in a large webbased study of 1468 undergraduate students participants reported a variety of consequences 271 felt embarrassed 247 reported emotional difficulties 208 experienced loss of respect and 10 reported difficulties with a steady partner in another recent study conducted on a sample of 200 undergraduate students in canada 78 of women and 72 of men who had uncommitted sex reported a history of experiencing regret following such an encounter a vast majority of both sexes indicated having ever experienced regret there were few sex differences in reasons for regret and better quality sex reduced the degree of regret reported it appears the method of asking participants whether and when they had experienced regret produces a sex difference but in terms of categorical presence it is most emerging adults who have experienced a kaleidoscope of reactions this is consistent with stinsons message of sexual development requiring experimentation including trial and error and good feelings and bad feelings on average both men and women appear to have higher positive affect than negative affect following a hookup those with positive attitudes toward hookups and approval of sexual activity show the greatest positive affect however there are also negative consequences experienced by both sexes in a study of 270 sexually active collegeaged students 72 regretted at least one instance of previous sexual activity in a report of 152 female undergraduate students 74 of women had either a few or some regrets from uncommitted sex 61 had a few regrets 23 had no regrets 13 had some regrets and 3 had many regrets further categorical presence of uncommitted sex in a females sexual history was related to higher overall regret scores from sexual activity although regret due to lack of commitment was not specifically addressed two types of sexual encounters were particularly predictive of sexual regret engaging in penetrative intercourse with someone known less than 24 hours and engaging in penetrative intercourse with someone only once among a sample of 1743 individuals who had experienced a previous onenight stand campbell showed that most men and women have combinations of both positive and negative affective reactions 10 garcia reiber massey and merriwether aq 12 tapraid5zrpgenpzrpgenpzrp00212zrp2214d12z xppws sϭ1 32112 518 art 20120423 following this event using evolutionary theory to predict responses of regret campbell showed that men had stronger feelings of being sorry because they felt they used another person whereas women had stronger feelings of regret because they felt used again both men and women had experienced some sexual regret but the frequency and intensity of negative reactions appeared to vary by sex with women more negatively impacted from some hookup experiences there are substantial individual differences in reactions to hookups not accounted for by gender alone among a subsample of 311 young adults with hookup experience when asked to generally characterize the morning after a hookup encounter 82 of men and 57 of women were generally glad they had done it the gap between men and women is notable and demonstrates an average sex difference in affective reactions yet this finding also conflicts with a strict sexual strategies model because more than half of women were glad they engaged in a hookup with respect to scripts although presumably being sexually agentic only slightly more than half of women were actually generally glad they had hooked up suggesting these encounters may not truly be pleasurable for all similarly in a study of 832 college students 26 of women and 50 of men reported a positive emotional reaction following a hookup and 49 of women and 26 of men reported a negative reaction these findings accord with the social sexual double standard creating greater pressure for women although the direction of the sex differences is in agreement with the evolutionary model that nearly a quarter of women report primarily positive reactions is inconsistent with a truly sexspecific shortterm mating psychology and with discourse messages of uncommitted sex being simply pleasurable also inconsistent with both of these theoretical models is that a quarter of men experience negative reactions taken alone neither a biological nor social model is sufficient to explain these individual differences some research has considered the interactions of sex and individual differences in predicting hookup behavior the mating intelligence scale designed to measure an individuals cognitive abilities in the evolutionary domain of mating was used to assess hookup behavior in a sample of 132 college students young men higher in mating intelligence were more likely than others to have hooked up with strangers acquaintances and friends while young women higher in mating intelligence were only more likely than others to have had more hookup experiences with acquaintances the authors proposed that given the potential risks and costs of sex to females sex with strangers would be disadvantageous and because women do not generally report having sexual motives toward opposite sex friends women with high mating intelligence were likely striking the optimal balance whereas men high in mating intelligence were obtaining maximum sexual encounters in this regard there are sex differences in cognitive processes but one cannot necessarily presume that the sexes vary fundamentally in their behavioral potentials rather they vary in their decisionmaking consistent with other evolutionary models it is still unclear the degree to which hookups may result in positive reactions and whether young men and young women are sexually satisfied in these encounters fine has argued that sex negativity is even more pronounced for women and the possibility of desire seems to be missing from the sexual education of young women armstrong england and fogarty addressed sexual satisfaction in a large study of online survey responses from 12295 undergraduates from 17 different colleges because cunnilingus often facilitates womens orgasm participants were asked about oral sex rates and orgasm in their most recent hookup and most recent relationship sexual event in this study men reported receiving oral sex both in hookups and in relationships much more than women in firsttime hookups 55 included only men receiving oral sex 19 only women receiving oral sex and 27 both mutually receiving in last relationship sexual activity 32 included only men receiving oral sex 16 included only women receiving oral sex and 52 included both mutually receiving in both contexts men also reached orgasm more often than women in first time hookups 31 of men and 10 of women reached orgasm in last relationship sexual activity 85 of men and 68 of women reached orgasm armstrong et al concluded with an important message a challenge to the contemporary sexual double standard would mean defending the position that young women and men are equally entitled to sexual activity sexual pleasure and sexual respect in hookups as well as relationships to achieve this the attitudes and practices of both men and women need to be confronted men should be challenged to treat even first hookup partners as generously as the women they hook up with treat them taken together this points to a need for further and more diverse attention to the impact of hookups on the physical and mental health of individuals as recommended by heldman and wade further more attention is needed on potential positive aspects of hooking up such as promoting sexual satisfaction and mutual comfort and enjoyment conclusion hookups are part of a popular cultural shift that has infiltrated the lives of emerging adults throughout the westernized world the past decade has witnessed an explosion in interest in the topic of hookups both scientifically and in the popular media research on hookups is not seated within a singular disciplinary sphere it sits at the crossroads of theoretical and empirical ideas drawn from a diverse range of fields including psychology anthropology sociology biology medicine and public health the growth of our understanding of the hookup phenomenon is likely predicated on our ability to integrate these theoretical and empirical ideas into a unified whole that is capable of explaining the tremendous variety in human sexual expression both evolutionary and social forces are likely facilitating hookup behavior and together may help explain the rates of hookups motivations for hooking up perceptions of hookup culture and the conflicting presence and lack of sex differences observed in various studies several scholars have suggested that shifting lifehistory patterns may be influential in shaping hookup patterns in the united states age at first marriage and first reproduction has been pushed back dramatically while at the same 11 sexual hookup culture aq 13 aq 14 tapraid5zrpgenpzrpgenpzrp00212zrp2214d12z xppws sϭ1 32112 518 art 20120423 time age at puberty has dropped dramatically resulting in a historically unprecedented time gap where young adults are physiologically able to reproduce but not psychologically or socially ready to settle down and begin a family and child rearing together the research reviewed here can help us better understand the nature of uncommitted sex today it is worth noting however that several shortcomings in our knowledge continue to impede the understanding of hookup behavior both the historical transformations that have resulted in the reordering of sexual scripts and the demise of romantic courting among emerging adults remain mysterious second recall bias may affect individuals reports of previous romantic and sexual engagements previous partners may be viewed as less desirable when individuals perceive their current partner as superior thus creating a dissonance effect much of the research asking participants about previous hookup relationships may therefore be biased due to recall third there exists a vast and rich literature on men who have sex with men specifically addressing casual sex and cruising among this population and typically focused on sexual health and hiv prevention the literature reviewed here primarily focuses on heterosexual hookups among emerging adults with some researchers not controlling for sexual orientation and others restricting to exclusively heterosexual samples future hookup research should venture into the msm literature to explore patterns of casual sex among these populations to understand other sexual subcultures where uncommitted sexual behavior is prevalent moreover there exists little published literature on the hookup patterns among lesbians and women who have sex with women last the crosscultural data provide a unique understanding of sexual behavior and romantic attachments some societies engage in sex for pleasure and others for procreation westernized culture often views sex as something for pleasure and fun which dramatically influences our sexual perceptions purposes and pleasures understanding hookups during the critical stage of late adolescent development and young adulthood is paramount for protecting and promoting healthy sexuality and healthy decisionmaking among emerging adults of the varied experiences and health risks young men and young women will experience perhaps none are as pervasive and widely experienced as engagement in and desire for romantic attachments and experiences with sexual activity indeed crosscultural anthropological literature suggests men and women will go to extreme lengths for love and sex this review suggests that uncommitted sex now being explored from a variety of disciplinary and theoretical perspectives is best understood from a biopsychosocial perspective that incorporates recent research trends in human biology reproductive and mental health and sexuality studies both popular scripts and predictions from evolutionary theory suggest that a reproductive motive may influence some sexual patterns such as motivation and regret following uncommitted sex however patterns of casual sex among gay men highlight inadequacies of the reproductive motive and suggest that further theorizing is necessary before a satisfactory evolutionarily informed theory can be established further the findings that a majority of both men and women are motivated to engage in hookups but often desire a more romantic relationship is also consistent with a more nuanced evolutionary biopsychosocial perspective that takes into account social context and the crosscultural and biological centrality of the pairbond hookups although increasingly socially acceptable may leave more strings than public discourse would suggest 1 tapraid5zrpgenpzrpgenpzrp00212zrp2214d12z xppws sϭ1 32112 518 art 20120423 tapraid5zrpgenpzrpgenpzrp00212zrp2214d12z xppws sϭ1 32112 518 art 20120423 18 tapraid5zrpgenpzrpgenpzrp00212zrp2214d12z xppws sϭ1 32112 518 art 20120423 jobname author queries page 1 sess 1 output wed mar 21 051838 2012 tapraid5zrpgenpzrpgenpzrp00212zrp2214d12z aq1 author apa uses merriamwebster and it spells the noun as hookup and the verb as hook up see changes here and below aq2 author provide a reference citation for hooking up aq3 author provide a reference citation for no strings attached aq4 author here and throughout please review your use of gender it seems as if in almost all cases you are discussing straight sex differences between male and female this being the case gender is not appropriate please change to sex aq5 author provide a reference citation for friends with benefits aq6 author provide reference for lippa or remove the citation aq7 author not clear whether by homosexual you mean gay and lesbian here or just gay relationships please be more specific aq8 author provide a reference citation for hook up aq9 author provide a reference citation for all the lovers aq10 author revisions to the sentence accurate aq11 author provide the page reference or something comparable if possible for the direct quotation aq12 author revision to the sentence accurate aq13 author provide page number of quotations from campbell aq14 author revision to the sentence accurate aq15 author note revisions to this citation hup is not listing this book as in press hence it has to be handled as per apa manual aq18 author note correction to order of authorship of welsh et al author queries author please answer all queries

hookups or uncommitted sexual encounters are becoming progressively more engrained in popular culture reflecting both evolved sexual predilections and changing social and sexual scripts hookup activities may include a wide range of sexual behaviors such as kissing oral sex and penetrative intercourse however these encounters often transpire without any promise of or desire for a more traditional romantic relationship a review of the literature suggests that these encounters are becoming increasingly normative among adolescents and young adults in north america representing a marked shift in openness and acceptance of uncommitted sex we reviewed the current literature on sexual hookups and considered the multiple forces influencing hookup culture using examples from popular culture to place hooking up in context we argue that contemporary hookup culture is best understood as the convergence of evolutionary and social forces during the developmental period of emerging adulthood we suggest that researchers must consider both evolutionary mechanisms and social processes and be considerate of the contemporary popular cultural climate in which hookups occur in order to provide a comprehensive and synergistic biopsychosocial view of casual sex among emerging adults today

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background notwithstanding that it is a concept that changes according to time and sociocultural structure violence has become one of the most prominent issues in recent years 43 acts of violence are behavioral patterns that are internalized in the socialization process by new generations and passed down to other generations in this manner 59 one of the most common forms of violence against women is domestic violence committed by a husband or partner intimate partner violence which is often referred to as domestic violence takes various forms 55 the intimate partner in such cases of violence is the husbandpartner with whom the woman has sexual intercourse with or the father of the child she carried in her womb 38 in the literature nonphysical violence is categorized into four different types emotional violence psychological violence social violence and economic violence 653 physical and sexual violence refers to the form of violence regarding physical intervention against women 2138 violence is defined as the exertion of physical force upon another person from which there is a strong possibility that murder injury psychological damage or other negative changes will result furthermore it is the use of physical force against oneself another person or a group that deliberately causes or is likely to cause injury death psychological harm negative development andor deprivation violence can be physical sexual or psychological in nature and can also include acts of deprivation or negligence 37 there is no doubt that sexual violence is one of the most dangerous types of violence women all around the world face the risk of physical or sexual abuse by an intimate partner or another offender 35 sexual violence and ipv can lead to physical injuries deterioration in mental health and specific chronic physical ailments in some cases such types of violence can even result in disability or death for some victims 18 sexual violence is a type of domestic violence that mostly occurs in marriage or intimate partnership scenarios 29 sexual violence and ipv are usually addressed together in such cases the concept of sexual violence by the intimate partner emerges and is very difficult to understand and measure as it includes both sexual violence and ipv 54 while the most common manifestation of this form of violence is rape or sexual assault women can also experience complicated situations such as coercion for sexual abuse or pornography threats and blackmail 13 sexual violence takes place in all societies around the world albeit under different definitions 33 sexual violence is defined as physically forcing another person to have sexual intercourse without their consent having sexual intercourse because of the fear of the partner and or being forced to perform a sexual act deemed humiliating 56 although sexual violence concerns both genders women are more likely to be victims and in most cases the perpetrators are male and known by the victim moreover children are particularly vulnerable to sexual abuse and girls are especially at greater danger at school 20 victims of sexual violence experience physical social mental emotional and sexual problems because of its severe psychological and sociological impact on the victim sexual violence further escalates feelings of helplessness and weakness that can drain the victims selfesteem and fuel a sense of vulnerability in the face of subsequent sexual violence 33 from a more general classification sexual violence results in the deterioration of mental and reproductive health and in the emergence of behavioral social and fatal consequences for the victim 17 in addition the expected results include hostility and blame on the basis of fear and anxiety in the short term and sleep disorders depression anxiety obsession acute stress disorder mental retardation and various significant health problems in the long term 46 sexual violence and forced sexual intercourse cause a range of gynecological and reproductive health problems such as hiv and other sexually transmitted infections unwanted pregnancy vaginal bleeding or infection myoma decreased sexual desire genital irritation pain during sexual intercourse chronic pelvic pain and urinary tract infections 44 furthermore they can causes shortterm problems such as shock fear anxiety panic phobias guilt sleep disorders eating disorders and longterm psychological problems such as anxiety disorder panic disorder depression and suicide attempts 32 moreover in extramarital affairs some of the other potential outcomes are the failure of victims to form adult relationships devalued expectations from marriage and rejection by family and friends in certain cultures there is even a possibility of beating or murdering the victim to protect the family honor 17 on an international level 30 of women experience some form of physical or sexual violence by their intimate partner during their lifetime in cases of femicide 38 to 50 of these acts are committed by the intimate partner a vast majority of victims choose not to report the violence or take action to protect their rights 57 which is why it is difficult to obtain statistical records of sexual violence the risk of facing sexual violence among women between the ages of 16 and 19 is four times higher than for other age groups and three times higher among women between the ages of 18 and 24 south africa ranks at the top of the global list of countries with the highest rates of sexual violence or rape and is followed by in descending the order botswana lesotho eswatini bermuda sweden surinam costa rica nicaragua and grenada with 15 incident per one hundred thousand people turkey is among the lowest ranking countries on this list 48 in turkey the laws regarding womens rights and violence against women are noticeably modernized however most women have no idea of their rights which may be due to the cultural norm that men own women manhood is all about violence and violence is just ordinary behavior in addition as turkish people commonly adhere to islamic norms which order women to be submissive to men it is generally accepted that rebelling against ones husband is a sin 36 as per the traditions and religious norms in turkey it is believed that violence sexuality and similar domestic matters should not be intervened with as women widely hold the belief that in marriage the sexual needs of men must be met they do not consider acts of sexual violence as criminal acts and never speak openly about these acts anywhere let alone to judicial authorities 29 the regulation on the implementation of the law on the protection of the family enacted in 2008 regulated the measures to be taken against family members committing violence and the procedures and principles regarding the implementation of these measures on combating violence against women the council of europe convention on preventing and combating violence against women and domestic violence also known as the istanbul convention was opened for signature in 2011 and came into force on 8 march 2012 this convention is one step ahead than former conventions in terms of the extended definition of violence against women and protecting and supporting women subjected to violence without considering stalking and cohabitation with the istanbul convention steps were taken to regulate the provisions of law no 4320 to prevent violence only in marriage in order to eliminate the flaws in the implementation of this law on march 8 2012 law no 6284 on the protection of the family and the prevention of violence against women entered into force law no 6284 aims to protect women children and victims of unilateral stalking who are married engaged divorced in a relationship or who ended a relationship and are exposed to violence or in danger of being exposed to violence by means of this particular law the scope of the protective measure decisions aimed at preventing violence against individuals exposed to violence were extended and measures such as changing the identity information of the individuals concerned were included moreover in order to be able to take preventive cautionary decisions against individuals who commit violence the powers of the law enforcement officers in addition to judges were restructured in cases where delays were inconvenient 23 the aim of these regulations is to prevent violence against women in a study conducted in ankara turkey with 1178 women via a questionnaire 313 of the respondents claimed to have experienced sexual violence from their husbands at least once while 258 of the respondents claimed to have been physically forced to engage in sexual intercourse moreover it was revealed that compared to the previous year the ratio of exposure to sexual violence had increased by 159 2 in a study conducted in turkey with 12795 women via a questionnaire 15 of married women between the ages of 15 and 49 reported to have experienced sexual or physical violence by their husband or intimate partner within the last 12 months in another study carried out in edirne turkey it was determined that the rate of exposure to sexual violence was 63 according to the findings of the study the decrease in social support and the breakdown of marital relationship increased sexual violence 42 in a study conducted on domestic violence including physical verbal economic psychological and sexual violence in eskişehir turkey it was determined that the prevalence of sexual violence was 69 26 in a study carried out in isparta turkey verbalpsychological physical emotional economic and sexual violence were addressed within the scope of domestic violence and the rate of the exposure to sexual violence by husbands was determined as 38 30 in a study conducted in konya turkey it was found that approximately 38 of women were exposed to sexual violence 3 violence against women has long been a research topic in the scientific world and has been investigated in various aspects in turkey the statistical methods or crosssectional data sets for sexual violence are relatively insufficient compared to other types of violence the present study aimed to fill this void in the literature by analyzing sexual violence via more specific variables in addition to crosssectional data sets and demographic variables in line with this purpose the factors that influence sexual violence against women were modeled for turkey via a rich data set methods study design the national research on domestic violence against women in turkey is one of the most comprehensive studies conducted nationwide in order to understand the dimension content causes and effects and risk factors of domestic violence experienced by women in turkey it was conducted for the first time in 2008 in order to determine the different aspects and reasons of violence against women and to meet the requirement of collecting data on this issue the national research on domestic violence against women in turkey conducted in 2014 is significant in terms of reflecting the change regarding violence against women since the research conducted in 2008 2223 the research questionnaire was designed by taking into account the questionnaire applied by the who in the study titled multicountry study on womens health and domestic violence against women 25 new questions regarding country specific requirements particularly targeting the monitoring of legal regulations were also added to the questionnaire 2223 setting within the scope of research on violence turkey has been divided into 30 strata in order to ensure obtaining estimates at country level urban rural level at 12 and 5 regions level except for the istanbul region which is among one of the 12 regions the distribution regarding urban and rural strata were at a rate of approximately 75 to 25 in the other regions in istanbul approximately 5 of the households were selected from the rural areas in the research settlements with a population of 10000 and above constituted the urban strata and those with a population less than 10000 constituted the rural strata the sampling of the research was carried out using cluster sampling 2223 the field study of the research conducted in 2008 started on 27 july 2008 and was completed on 29 september 2008 22 the field study of the research conducted in 2014 started on 8 april 2014 and was completed on 11 july 2014 23 variables according to the national research on domestic violence against women in turkey the following questions related to sexual violence were directed to the participating women has your husband or one of your intimate partners exerted physical force to have intercourse with you have you involuntarily engaged in sexual intercourse because of fear of potential threats from your husband or one of your intimate partners and has your husband or one of your intimate partners force you to perform a sexually demeaning or disgraceful act the womens experiences of sexual violence measured by these questions were used to create a dependent variable if the participating women had experienced one or many of the abovementioned cases they were deemed to be a victim of husbandpartnerinflicted sexual violence however if none of the cases were experienced they were deemed to have not experienced sexual violence thus the dependent variable code 1 was assigned to women who had experienced sexual violence and the dependent variable code 0 was assigned to those who had not data sourcesmeasurement in this study the crosssectional data of the national research on domestic violence against women in turkey conducted in 2008 and 2014 by the institute of population studies of hacettepe university were used the survey questionnaires of the national research on domestic violence against women in turkey were implemented by the research team ethical rules developed by the who were followed at every stage of the study and various measures were taken to ensure the safety of both the participating women and the research team written consent was obtained from the participants before each interview the researchers received traing on ethical and safety rules and conducted themselves in accordance with sensitivity of the subject at the beginning during and after the interview process the interviews were conducted with one woman from each household in the event of there being more than one woman in the 1559 age group in the household the participating woman was chosen by using a random method in order not to ask the same questions to more than one woman in the same household the researchers were very meticulous in ensuring that the interviews were conducted in an isolated environment moreover all interviewers were trained on the confidentiality of the interviews during the process of obtaining consent and providing information regarding the content of the study the participants were informed that their answers would be kept confidential 2223 bias the data regarding womens history of exposure to sexual violence were the subjective responses of women thus there was a decided risk that any data obtained by this method could be biased study size in the research conducted in 2008 the questionnaire was completed by interviewing 12795 women face to face and the rejection rate was 21 the response rate for the interviews conducted with the women was 861 22 in the research conducted in 2014 the questionnaire was completed by interviewing 7462 women face to face and the rejection rate was 44 the response rate for the interviews conducted with the women is 833 23 the weights calculated in accordance with the sample design of the research were added to these data sets 2223 quantitative variables in this study questions related to sociodemographic and economic characteristics and domestic violence were directed to the participants and some of the variables thought to be influential were then integrated into the model the region variable was one of the independent variables in the study at the basis of employing the nomenclature of units for territorial statistics in turkey lies the obligation to establish development agencies 4 following the nomenclature of units for territorial statistics at level 1 turkey was divided into 12 regions in order to obtain more meaningful results from the analysis some of the regions were unified and then grouped into eight regions 16 these regions and the cities within the regions are depicted in detail in table 2 all of the analyzed variables were categorical variables and nominal or ordinary scales ordinal and nominal variables were described as dummy variables in order to observe the impact of the categories belonging to all the variables that would be integrated into the binary logistic regression and binary probit regression models 589 statistical methods survey statistics in stata 15 were used to account for the complex sampling design and weights weighted analysis was performed in addition bivariate analysis was performed to identify the relationships between the dependent variable and various factors the bivariate relationships were predicted by evaluating significant differences using pearsons chisquare tests for the categorical variables pearsons chisquare not only provides information regarding the significance of the observed differences but also provides detailed information about the categories of any differences found 7 binary logistic regression and binary probit regression analyses were conducted to determine the risk factors that were influential on the exposure to sexual violence these particular analyses are used to study the relationship between the dependent variable and the independent variable in cases where the result variable has two options binary logistic regression not only provides the opportunity to evaluate the statistical significance of each independent variable as a risk factor but also the opportunity to calculate the odds ratio the cumulative logistic distribution function is used in the binary logit model and the cumulative normal distribution function is used in the probit model although the logit and probit models have qualitatively similar results the predicted values of the two models cannot be directly compared the fact that normal cdf contains integral calculations is cited as a factor leading to a more widespread use of logistic cdf in practice 7 results characteristics of the participants in this section the frequency and percentages of the independent variables related to the model to be established are provided and interpreted in table 3 influential factors on womens exposure to sexual violence and the chisquare test statistics are provided based on the findings displayed in table 3 the participants who took part in the research in 2008 constituted 633 of the sample women who experienced firstdegree relative violence represented 116 of the sample the chisquare test statistics of all the variables were determined to be significant women whose husbandspartners were illiterate made up 39 of the sample and whose husbandspartners were elementary school graduates made up 422 of the sample women whose husbandspartners were unemployed represented 184 of the sample while whose husbandspartners worked in the private sector represented 67 of the sample women whose husbands partners drank alcohol constituted 207 of the sample and whose husbandspartners gambled constituted 21 of the sample women whose husbandspartners were unfaithful constituted 89 of the sample women who had experienced economic violence formed 277 of the sample women who had experienced verbal abuse formed 432 of the sample and women who had experienced physical violence represented 366 of the sample multivariate analyses in this study the binary logistic regression and binary probit regression models were employed to determine the factors that influenced the likelihood of women experiencing sexual violence the results of the estimated model are given in table 4 average direct elasticities the marginal impacts of the factors influencing womens history of sexual violence can be seen in table 5 in the model created in the study the existence of multicollinearity between the independent variables was also checked and it was suggested that a variance inflation factor value of five and above caused a moderate level of multicollinearity while a level of 10 and above caused a high level of multicollinearity 59 the vif results displayed in table 5 indicated that there was none of the variables could cause a multicollinearity problem table 5 presents the goodness of fit of the estimated models which revealed that the results obtained from both models were identical the accurate classification of the binary logistics and binary probit models was computed as 8694 and 8683 respectively the fitness criteria for the model provided similar results for both models and were in an acceptable range for these kind of models according to the results of the binary logistics model presented in table 5 women who participated in the research in 2014 were 2647 less likely to face sexual violence from their husbandspartners compared to women who participated in the research in 2008 women residing in the tratrb region were 4316 more likely to face sexual violence compared to women residing in the tr1 region women residing in the urban area were 97 less likely to face sexual violence compared to others women in the age group of 3544 years were 264 less likely to face sexual violence compared to women in the age group of 1524 years women who had never attended school were 327 more likely to face sexual violence compared to women who graduated from a university employed women were 164 more likely to face sexual violence compared to unemployed women women who had never been married were 1481 less likely to face sexual violence from a husbandpartner compared to women who were widoweddivorcedseparated women with an excellentgood health condition were 253 less likely to face sexual violence compared to women with a poorvery poor health condition women who had children were 245 less likely to face sexual violence compared to women who had no children women who had been exposed to first degree relative violence those whose husbandspartners used drugs those whose husbandspartners had been unfaithful those who had been subjected to economic violence by their husbands partners those who had been exposed to verbal violence by their husbandspartner those who had been subjected to physical violence by their husbandspartners were 264 6098 4213 6296 12433 and 12846 more likely to face sexual violence compared to other women respectively women whose husbandspartners had not attended school were 3701 more likely to face sexual violence compared to those whose husbandspartners were primary school graduates women whose husbandspartners were unemployed were 267 more likely to face sexual violence compared to those whose husbandspartner worked in the public sector according to the binary probit model results presented in table 5 women who participated in the study in 2014 were 3445 less likely to face sexual violence from their husbandspartners compared to the women who participated in the study in 2008 women residing in the tra trb region were 5515 more likely to face sexual violence compared to women residing in the tr1 region women residing in the urban area were 1239 less likely to face sexual violence compared to others women in the age group of 3544 years were 3217 less likely to face sexual violence compared to women in the age group of 1524 years women who had never attended school were 4143 more likely to face sexual violence compared to women who had graduated from university employed women were 2027 more likely to face sexual violence compared to unemployed women women who had never been married were 17842 less likely to face sexual violence from a husbandpartner compared to women who were widoweddivorcedseparated woman with an excellentgood health condition were 3143 less likely to face sexual violence compared to women with a poorvery poor health condition women with children were 3059 less likely to face sexual violence compared to women who did not women who had been exposed to first degree relative violence those whose husbands partners used drugs those whose husbandspartners had been unfaithful those who had been subjected to economic violence by their husbandspartners those who had been exposed to verbal violence by their husbands partners and those who had been subjected to physical violence by their husbandspartners were 3397 7899 56495 7698 13717 and 14413 more likely to face sexual violence compared to other women women whose husbandspartners had not attended school were 4393 more likely to face sexual violence compared to those whose husbandspartners were primary school graduates women whose husbandspartners were unemployed were 347 more likely to face sexual violence compared to those whose husbandspartners worked in the public sector discussion in this study the factors that influenced sexual violence against women in turkey were investigated by employing binary logistic and binary probit regression analyses according to the results of the analyses women who participated in the questionnaire in 2014 were less likely to experience sexual violence compared compared to women who had participated in the 2008 questionnaire it can be stated that the legal regulations adopted for the prevention of violence against women 2008 had a substantial influence on this decrease 23 based on the model estimation results it was determined that women living in the western anatoliacentral anatolia regions the western black seaeastern black sea regions and the northeastern anatoliaeast central anatolia regions were more likely to experience sexual violence compared to women living in istanbul in parallel with these results in a study conducted in turkey it was reported that women living in eastern and southeastern regions were more likely to experience sexual violence compared to those living in western regions 58 it is generally accepted that the abovementioned regions are at a lower development level than istanbul moreover urban development offers opportunities to stem the tide of violence against women in terms of forbearance access to economic sources assets corporate assistance and support 39 it was determined that women living in urban regions were less likely to experience sexual violence compared to those living in rural regions the fact that women living in urban areas have easier access to the internet newspapers tv and similar media outlets and possess a higher awareness of their legal rights and the fact the these conditions mostly apply to their husbandspartners could also be factors behind this conclusion similarly in a study conducted with married women in bangladesh it was determined that the women living in rural areas were exposed to sexual violence more frequently than those living in urban areas 40 in a togobased study carried out among married women it was determined that those living in cities were less likely to experience sexual violence 45 the economic differences between the rural and urban areas may be influential in this result poverty which is prevalent more commonly in rural areas than urban areas gives rise to domestic stress and therefore paves the road for violence furthermore the factor of isolation in rural areas decreases the chances for women exposed to violence to access assistance and thus increases the risk of violence towards women 10 the general acceptance of the abuse of women in rural areas and the relevant social norms that prohibit abused women from speaking publicly and pursuing social support also reduce the likelihood of women reporting abuse to law enforcement authorities 49 based on the age variable it was determined that women within the age ranges of 2534 years and 3544 years were less likely to experience sexual violence compared to those within the age range of 1524 years in a usabased study an increase in age was reported to move in parallel with a lowering risk of sexual violence 52 different from this situation it was reported in a study conducted in east india that an increase in age further increased the risk of experiencing various types of violence 12 the correlation between sexual violence and age is quite complicated the changing economic contribution of women in society is a function of time and age it has been stated that the influence of economic contribution and age along with the changing gender roles and types of violence are required to be researched longitudinally in detail 19 in terms of the level of education variable it was determined that the illiterate women were more likely to experience sexual violence compared to those who were university graduates similar to this finding a study carried out in nepal determined that uneducated women were at a greater risk of sexual violence from their intimate partners compared to educated women 11 in a study conducted in serbia it was determined that women with a lower level of education were more likely to experience physical or sexual violence 24 findings from a study conducted in various regions of india indicated that a higher level of education decreased the possibility of women experiencing violence and sexual abuse from their intimate partners 47 in addition it was found that women who were employed were more likely to experience sexual violence compared to those who were unemployed in parallel with this result a study conducted in indonesia reported that women with financial independence were more prone to experience sexual violence 28 moreover it was concluded in a study conducted in india that married women were at high risk of being exposed to both physical and sexual violence 34 women who earn money can be perceived and considered as a threat to male dominance in patriarchal families according to the traditional power structure 34 arguably in the event that women start earning money and contributing to the household income they gain further independence and awareness of their rights and therefore may challenge the traditional gender norms husbands who become anxious about safeguarding and maintaining their authority may respond to this situation with increased violence 19 women who were single or married were less likely to experience sexual violence compared to those who were widoweddivorcedseparated similar to this finding a study based in the usa revealed that divorced and separated women had a higher likelihood of being exposed to sexual violence compared to married women 52 in most cases it is unlikely that married men will practice sexual violence as marriage is based on mutual consent 14 women with children were less likely to experience sexual violence compared to those with no children in parallel with this result a study conducted in nepal found that the absence of children in a family increased the likelihood of a womens exposure to sexual and intimate violence 11 women whose husbandspartners were illiterate faced a higher possibility of sexual violence than women those husbandspartners were elementary school graduates furthermore women whose husbandspartners were high school graduates faced a lower possibility of sexual violence than those whose husbandpartners were elementary school graduates in a study carried out in indonesia it was concluded that women whose husbands had less than nine years of education faced a higher possibility of physical and sexual violence 28 in addition a study in serbia revealed that the lower the husbandpartners level of education was the higher the risk of physical or sexual violence risk for the woman became 24 a study conducted in ankara turkey concluded that as partners level of education increased an inverse fall occurred in the frequency of womens exposure to sexual violence 2 as partners with an education beyond secondary school education consider and perceive each other more as estimable the probability of them exploiting and abusing each other could be to a lesser extent 1 it is highly probable that women whose husbandspartners are unemployed are more likely experience sexual violence it was reported in a study conducted in india that women whose partners were employed were less likely to be exposed to violence 34 similarly it was concluded in a study conducted in spain that the increase in male unemployment at a regional level increased the possibility of violence towards an intimate partner 50 this is an anticipated consequence theoretically male unemployment not only increases the stress but also results in further abuse and exploitation by undermining the control and economic security feelings of males and can create a further control impulsion on their partners 51 at this point unemployment insurance welfare aid and entitlement programs designed to alleviate and diminish economic challenges and difficulties could be effective in reducing the violence towards intimate partners 27 the present study determined that women whose husbandspartners used drugs were more likely to experience sexual violence similarly in a study conducted in serbia it was determined that women whose husbands partners took drugs were more likely to experience sexual or physical violence 24 worse still is the instances where the perpetrator drugs the drink of the victim to facilitate sexual assault in such cases although the effects may vary based on the type of substance it prevents the victim from resisting against sexual assault and thus facilitate sexual assault 15 women whose husbandspartners were unfaithful were more likely to experience sexual violence compared to those whose husbandspartners were faithful in a study conducted in indonesia it was determined that women with unfaithful husbandspartners were exposed to higher rates of sexual violence 28 additionally a vietnambased study revealed that women with unfaithful husbandspartners were more prone to experiencing several types of violence including sexual violence 31 in a study conducted in turkey it was determined that women with unfaithful husbandspartners were exposed to nearly twice the rate of sexual violence those whose husbandspartners were faithful were exposed to 58 in addition women who experienced economic verbal physical abuse and violence from firstdegree relatives were more prone to experience sexual violence compared to those who had never experienced such forms of violence in a study conducted on various ethnic origins in nigeria it was determined that domestic violence was directly correlated with physical psychological and sexual violence 41 according to the results obtained from a study conducted in ankara turkey 576 of women who were exposed to sexual violence had also been subjected to physical violence while 845 had also been subjected to economic violence and 725 had also been subjected to emotional violence 2 furthermore it was reported that experiencing physical violence in the past elevated the risk of exposure to sexual violence hence it was concluded that violence against women is indeed a unity and violence in any form is part of a chain reaction that leads to violence in multiple forms this study had a number of limitations firstly the data in the study were secondary data the variables essential for performing statistical analyses consisted of the variables in the data set however some variables including profession and home ownership status were missing in the data set and therefore could not be included in the analysis secondly as the data was crosssectional the definite causal relationship between sexual violence and the related factors could not be inferred conclusion this study was conducted with women living in turkey and used data collected on two different dates it is suggested that the obtained findings can lead the way for other studies that harness different econometric models and variables through employing crosssectional data sets on sexual violence in turkey in relation to the envisaged measures to stop violence against women these findings can also offer guidance to the related governmental bodies by forming multivariate models that cover all of the aforementioned types of violence analyses could be conducted in connection with the types of violence in the future abbreviations vif variance inflation factor std error standard error competing interests the authors have no competing interests to report additionally the authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis • 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 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background sexual violence is one of the most investigated types of violence by national and international decision makers the purpose of this study was to detect the factors that affect sexual violence against women in turkey

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introduction along with the rapid urbanization and increasing levels of population ageing in contemporary china levels of olderage migration are increasing in beijing the capital city this population ageing is exacerbated by a growing floating population in beijing which refers to internal movement of chinese residents to places where they do not hold local household registration status 1 the hukou system was introduced in the 1950s as a method to regulate ruralurban migration where moving between rural and urban localities required official permission each citizen was classified within an agricultural or nonagricultural hukou with nonagricultural citizens receiving educational health care pension benefits not available to their agricultural rural counterparts 23 in 2000 the floating population was 256 million in beijing which included 63700 older migrants in 2010 the floating population increased to 704 million among which the older migrants increased to 238000 45 the destinations of older migrants are consistent with the younger generation 6 nearly 90 of the total older migrants moved to the urban functional extension area and urban new developing area which are newly developed areas in beijing 78 this olderage migration to urban areas can be somewhat attributed to the rapid socioeconomic changes that occurred as a consequence of the chinese economic reform at the end of the 1970s during this period many workingage chinese relocated to megacities such as beijing either because they were educated and found better employment in megacities or they migrated from rural areas to urban areas seeking employment opportunities consequently parents of these workingage populations are also relocating in increasing numbers in order to provide childcare or access care and support as they age 6 existing studies have found that family factors play an important role in older peoples decision making around migration in china when migration destinations motivations and perceptions of chinese rural and urban elderly are compared family factors such as caring for grandchildren were the main migration motivation for the urban older adults whereas searching for employment opportunities or receiving care and support from their children were the main factors for their rural counterparts 9 10 11 12 13 zhou 14 found that intention to migrate was generally low among chinese older people with availability of social networks housing conditions and climate in the destinations having a significant impact on willingness to migrate consequently this group have much synergy with the socalled zero generation or transnational flying grannies increasingly being reported in recent migration studies 1516 where older populations migrate to host countries to provide childcare within transnational families the vulnerability and invisibility of this zero generation often results in a policy vacuum 17 however the vulnerabilities of older migrants increase with age and time as their own health and care needs change through the life course and their accessibility to health care in their new places of residence is rather scarce 17 in relation to health and quality of life older migrants are already a vulnerable group due to increased risk of poor physical and mental health poor adaptation to changes in living environments and exclusion from care and welfare services 1819 in china ruralurban older migrants are even more vulnerable because of their relatively poor socioeconomic status and accessibility to social welfare low educational level and differences in lifestyle compared to their urban chinese counterparts older peoples access to pensions and health care insurance are determined by where the persons hukou is and a lack of urban hukou restricts the ability of citizens to access health and welfare services in the place they live 23 since the 1950s urban employees have enjoyed pension benefits but rural residents and urban nonemployed residents were excluded from such social welfare in 2014 the urban residents pension plan and the new rural social pension system were merged into a unified basic pension insurance plan for rural residents and nonemployed urban residents however the benefit amount of this plan is very low with a country average of 81 rmb per month while the average household consumption per month in rural areas was 896 rmb in 2016 20 with regard to health care insurance by the end of 2013 95 percent of urban employed workers nonemployed residents and rural residents were covered by one of the medical insurance schemes namely urban employee basic medical insurance urban resident basic medical insurance and new rural cooperative medical insurance however even with these social welfare reforms great disparities still exist between the urban and rural residents in various regions ruralurban older floating populations also face difficulties in accessing social welfare in the place where they were registered as they no longer live there it is also more difficult to obtain reimbursement for hospitalization costs if they go to the hospitals outside of the regions where they are registered 21 literature on migration in both developed and developing countries mainly focuses on working age migrants 22 23 24 25 26 the study of older migrants especially rural to urban older migrants however is a relatively new field and remains marginal in migration studies social gerontology health and social geography researchers in englishspeaking countries have undertaken studies on olderage migration since the 1960s existing studies focus on postretirement moves such as older migrants living in the northern us moving to the sunbelt areas 27 older people migrating to live with adult children or relatives 28 and relocation to residential care facilities 29 many studies focus on the migration destinations motivations decisions and experiences of older people and the implications for ageing services and policy 30 31 32 33 34 35 36 37 38 39 consequently mobility and vulnerability are two important concepts in the study of older migrants mobility is a key concept in migration research and transportation geography it links the movements of a variety of things including humans ideas and objects across different scales of moving in relation to forms of places stopping stillness and relative immobility 40 ones capacity to be mobile is dependent upon all sorts of social political cultural and economic contextual variables from physical aptitude aspirations to settle down other existing technological transport and telecommunications systems and their accessibility to spacetime constraints such as the location of the workplace 41 the critical turn underway in health and social geography emphasizes a shift from quantitative studies using statistics to qualitative studies focusing on personal intimate and indepth engagement with older people themselves 42 increasing attention has been dedicated to the social impact of amenityled mobility in older age by looking at the degree of social relations in the local community and their social embeddedness 154344 however from the chinese perspective the majority of existing research focuses on the migration of the labor force from inland china to the more developed east regions of china by using statistical methods national census data and social surveys to analyze migration patterns among older people 10111345 few studies have used qualitative methods for understanding older migrants mobility and migration decisions and there has been no work exploring the intersection between older ruralurban migrants mobility and migration processes it is important to understand mobility because the various forms of mobilities impact older ruralurban migrants willingness to migrate experience of migration and their likelihood of staying in the new destination cities beijing as one of the cities with the largest number of older ruralurban migrants in china is used as a case study site within this research to explore how ruralurban migration among older chinese is influenced by and impacts on their mobilities the purpose of this study is to provide a conceptual framework for rapidly developing countries and demonstrate its value in exploring migration behaviours among older chinese migrants these results will shed light on behaviours relating to ruralurban migration among older people which is important for future service planning to improve their health and wellbeing the following section reviews the literature related to mobility and introduces the conceptual framework of this study the methods and results are discussed in the third and fourth sections with conclusions and discussions presented in the last section of this paper conceptual framework there are various forms of mobility inclusive of but not limited to physical mobility social mobility and economic mobility mobility is not only the potential to be mobile but is also the ability to turn that potential into an actuality which is influenced by physical sociocultural and economic factors 41 peoples potential mobilities are constrained by the particular spacetime prism they belong to which is defined by their class identity income or other characteristics mobilities are also socially differentiated and are linked to a wider context of established societal norms codes of conduct belief systems and ideologies 46 insufficient mobility may threaten social inclusion because of reduced accessibility to opportunities services and social networks 47 people may have little choice because of the sorts of mobile societies they must move within researchers have also sought to understand the relationship between mobility and privilege politics and exclusion 48 some studies have focused on the inequalities and exclusion of mobility practices and spaces among marginalized groups to understand the diverse experiences particular social groups may have of mobility 4950 these studies show that mobilities have a significant impact on peoples decision to migrate and behaviors associated with migration as well as their ability to adapt in terms of vulnerability bustamante et al 51 identifies mobile vulnerability as a social condition where the human rights of migrants are violated multiple vulnerabilities associated with mobility were identified among migrants which were associated with language and cultural barriers ethnicity race or low socioeconomic status based on the review of the literature this study will investigate the physical economic institutional and sociocultural aspects of mobility based on the forms of mobility and its consequences we are proposing this conceptual framework as a way to understand the vulnerabilities that older ruralurban migrants face and the role of agency in developing coping strategies that help them adapt to the new living environment physical mobility refers to the physical capability of an individual to migrate and adapt to the new living environment economic mobility refers to the financial affordability of migration and cost of living in the migrants destination institutional mobility refers to mobility that is affected and restricted by policies and regulations for example limited social welfare benefits for older ruralurban migrants at the destinations restricts their mobility social mobility refers to mobility affected by ones social connection and embeddedness within the area of origin and destination while cultural mobility refers to ones mobility affected by cultural norms and habits within society the mobile vulnerabilities that older migrants experience and their adaptive capacity influence their likelihood of staying in their new destinations the frameworks developed in developed countries however do not take into account the kind of issues that exist in rapidly developing countries such as china chinese older people face various challenges associated with ruralurban migration such as access to social welfare benefits the household registration system psychological adaption and the availability of care resources 9 in this study we will conduct empirical research to test the conceptual framework proposed in figure 1 data and methods to answer the research questions 45 structured indepth interviews were conducted with older people aged 60 and over in four sites in beijing including two residential quarters the campus of beijing normal university and a park all the four sites are located in the urban function extension area of beijing where most of the older migrants are located more detailed information on the four sites are introduced below the demographic characteristics of the participants are listed in table 1 participants were aged between 55 and 86 and had been living in beijing for two months to 30 years beichenfudi community is located in chaoyang district established in 2011 it was a social housing project with a relatively low price for rent and sale the total number of households in this community is 3891 with 15000 permanent residents the population aged 60 and over is 1950 which accounts for 13 percent of the total residents beitucheng park is a public park built on the historical site of the old city wall it provides open space for recreation ecological protection and emergency shelter there is fitness equipment available in the park it is easily accessible by public transportation and attracts many older people who live close to the park to exercise and carry out various social activities such as chorus dancing and tai ji in the park changanxincheng community is located in fengtai district it was one of the first social housing projects built in beijing in 2002 the total number of permanent households is 4700 with 12000 permanent residents the population aged 60 and over is 2100 which accounts for 175 percent of the total residents the campus of beijing normal university is located in haidian district the residents include the families of university faculty staff members and retirees many social activities including singing group calligraphy and handcrafting are also organized some contract workers who are responsible for cleaning and gardening on campus are ruralurban migrants including some older migrant workers convenience sampling was conducted in the open space of the four study sites which are popular gathering places for chinese older adults six research assistants went to the four study sites to interview participants during the daytime in april 2017 interviewers approached potential participants within these public areas to ascertain if they met the age criteria had migrated from rural china to urban beijing and still held rural household registration if they met these criteria they were provided with information about the study and invited to take part in an interview interviews covered demographic information reasons for migration impact of migration on health and quality of life level of adaptation and adaptation strategies patterns of health care utilization and plans to stay in beijing ethical approval was received from the la trobe university human ethics committee interviews were audiorecorded with participant permission and transcribed into mandarin and english the analysis of the data is based on the constant comparative method 52 53 54 transcripts were opencoded and the physical economic institutional social and cultural aspects of mobility were summarized based on the opencodes following the interview questions and the themes how older people adapt to the new environment and their likelihood of staying in the destination were also analysed transcripts were coded deductively by the first author and two research assistants in relation to the interview questions this coding was then ratified by other coauthors and discussed in relation to key themes results the majority of participants are married and have lived in beijing for more than one year some had lived in beijing for an extensive period which suggests that while they had migrated they were to some extent ageing in place the majority also had less than nine years formal education and 29 out of the 45 participants receive less than 1890 rmb per month which is the minimal wage in beijing in 2016 two thirds of the participants were farmers before they migrated to beijing and one third were employed before their migration for the younger participants caring for grandchildren was the major reason for migration to beijing while some migrated to beijing for economic reasons as they are still capable of making money by doing physical work in contrast the major reason for the oldestold to move was to live closer to their family members for elderly care and health care there was consensus among the five authors that mobile vulnerability was a prominent theme the vulnerability experienced by ruralurban migrants related to various forms of mobility including physical economic institutional and sociocultural components of mobility their coping strategies to adopt the new living environment and their willingness to stay in beijing were also discussed physical mobility from the individual perspective the physical mobility of older migrants changes through the life course the change of mobility influences the reasons for migration the older migrants move due to economic driving forces or to provide childcare for their grandchildren when they are physically capable their purpose for migration changes to seeking care support from their adult children when their physical mobility declines some older migrants reported that their willingness to stay in beijing depended on their health status and mobility the two quotes below reflect the various motivations for migration related to physical mobility my son is still young not married yet i am working here my son needs a large sum of money young men need a lot of money to get married in rural areas i am 87 this year i came here for better health care i could die in half an hour when the heart disease occurs everything is expensive here but i have no choice it is well recognized that access to transportation improves peoples physical mobility the increasing use of private cars and highspeed trains made it much more convenient for the older migrants to travel between their hometown and beijing this increase in physical mobility somehow increased their willingness to migrate however participants also mentioned that this improved access to public transportation was contingent on their adult children to offering rides or financial support for travel expenses and this vulnerability relating to physical mobility and financial affordability limited their ability to travel physical mobility is also linked to the mobility older migrants experience within their living neighborhood ruralurban older migrants are more vulnerable compared to their local counterparts due to their unfamiliarity to the new living environment inadequacy of spare time loneliness and language barriers which limit their physical mobility even though some participants mentioned the free bus they can use in beijing few of them actually used the public transportation alone due to limited spare time or lack of familiarity with their living environment i was quite upset during the first two years i was here i felt i was a stranger in a strange place i did not know the people here and i was not well educated i did not dare to go anywhere people come here park to dance or do some exercises i dont have time i just come out for a walk then i get to go back home to cook care for the kid and clean the apartment economic and institutional mobility postmigration participants demonstrated a strong sense of vulnerability related to their economic status in some cases older migrants intended to temporarily migrate to beijing and planned to move back to their hometowns because of their vulnerable economic and institutional mobility many of them migrate to provide care support for their grandchildren low income small living space high living expenses and health care costs limited their mobility which resulted in high financial dependency on their adult childrens family when the grandchildren grow up they would be forced to move back to their hometown due to these reasons i dont want to come here i dont want to stay here for one more day this is not my home and i dont have money ah nowadays the kids need to be picked up and sent to school even when they go to primary school i cannot think anymore and i dont want to think more about it sometimes it makes me upset to think about these things when the kids grow up i am old and i cannot stay here anymore then i have to go home i cannot do anything when i go home and i will be upset again but to stay here it wont work my grandson needs space right it is not to say my daughter doesnt show her filial respect to me they are not able to do that how can they show their respect they work hard and are tired they only get this small space right the social welfare that ruralurban migrants can access ties to their hukou instead of their living place which affects their institutional mobility rural older adults are less likely to have access to state supported social security benefits in the rural system and more likely to rely on support from their adult children consequently many participants reported that they intended to live in beijing on a temporary basis to provide childcare while they were physically capable but would eventually like to move back to their hometown because they did not have the hukou to access social welfare benefits in beijing this vulnerability in economic and institutional mobility experienced by the rural older migrants is obvious and influenced their sense of belonging in beijing and willingness to stay yes i come here just for providing support to them you dont have money and you dont own housing there is no living space for you when the kid grows up he needs space its no better than going back home to live in my own small house here i dont receive any health care benefits in my hometown i can get 50 reimbursement for medical cost now we have the rural cooperation medical plan in rural areas my husband was retired from the company so he can receive 90 percent reimbursement for his medical cost the beijing municipal government however is making efforts to gradually improve social welfare benefits for the older migrants for example older migrants who aged 65 and over and have lived in beijing for more than six months can apply for an elderly bus card which provides them with free access to the bus system in beijing the bus is free for the older people by using the elderly card it is convenient the older people can apply for such card if they stay long enough i applied for the elderly card here and i have been here for nine months it is long enough we applied for it in the community by providing my daughters id card and certificate for residence it is convenient for the older people to live here once they have the medical card and bus card sociocultural mobility along with the physical economic and institutional vulnerabilities that older migrants experience related to mobility sociocultural norms also have impacts on older migrants mobility and vulnerability for ruralurban older migrants a strong sense of filial piety and family ties associated with traditional chinese culture still plays an important role in decision making relating to elderly care as older migrants physical mobility decreases with age they also face challenges associated with financial security and health status they are more likely to seek family support by moving to beijing to live with their adult children due to the inadequacy of care support in their rural hometown when i get old and i dont have selfcare ability in the future who will care for me it is impossible for my children coming back to care for me if i move back to my hometown it is all right my son and daughter are living here i wouldnt move here if they dont live here however the experiences of coresidency with their childrens family were not always as enjoyable as they expected some older migrants talked about conflicts in the family when they lived with their children which influenced their perceived experience of migration it is not i am willing or unwilling to migrate i have to come even if i am unwilling to do so there is no choice of course i was not used to live here when i first moved here i am not used to live with my son and daughter in law the living space is small and the living habit is different it is not convenient the housing is different from the rural area i am a total stranger and unfamiliar with the place and people there is no choice and i am not willing to come it is not an obligation but i also have the responsibility to support them older peoples authority within ones household in the traditional chinese culture is challenged in modern society especially for the older migrants the implementation of the onechild policy enhances the worries of the older migrants about the care burden on their child quite a few participants mentioned that their willingness to stay in beijing was dependent upon their childrens decision my son wants me to stay here i have only one son and no more child i am the first cohort who has the onechild post 80s right i am not thinking about going back home it is so lonely to go back and my son is going to be worried about me right his father has passed away and i stayed in the hometown by myself for ten years the housing in my hometown is not sold yet if it is too much burden for my daughter in the future we will go back home to move into residential care facilities if we move to the residential care facility in beijing with our little pension we dont think we can go to a good one we will take my daughters advice cultural factors also impacted their willingness to remain in beijing for example one older migrant reported that his willingness to stay in beijing was impacted by the different cultural norms associated with funerals and he wished to move back to his hometown to follow his familys burial traditions i dont want to be cremated here i want to rest in a coffin and be buried with the ancestors together social exclusion and loneliness of older migrants is shown to vary greatly depending not only on individual characteristics but also on environmental circumstances some participants mentioned that they were busy with childcare and household chores which left them little time to build a social network or attend in any social activities in the new living environment although older migrants are vulnerable due to their relatively low socioeconomic status in beijing and high dependency on their childrens family some migrants manifest agency and develop strategies to cope with the real and potential vulnerabilities they put efforts in building a new social network through caring for the grandchildren there are many older people coming here to care for the grandchildren we get in touch with others sometimes we all come out with the kids and we get together to chat a little bit personal attitudes towards population ageing also impacted on decisions relating to migration active ageing is beneficial for keeping ones mobility both physically and socioculturally and it was mentioned by some older migrants when explaining their reasons for migration my children all moved to cities i dont want to stay at home and i am tired of doing the farm work i moved to beijing for work i am a gardener now i have less workload and make more money as a farmer doing physical work is a way to keep fit the other good thing is that i got to live in the capital city and visit many places of interest and parks the new social connection with the local residents or other migrants helped the older migrants feel more sense of belonging within their communities older migrants also received support from their families and stayed connected with the home environment through the use of communication technology such as cell phones and wechat which decreased the psychological distance between beijing and their hometowns some had adapted to their new life postmigration after a longer period of residence in beijing my health status has improved after the migration i have set up my routine here which i did not have when i was in my hometown just doing my farm work and having meals after finishing the work here is different i eat and come out for a walk on a fit schedule when i first came here my health status was not so good as before i was not used to moving here my health status was even worse than i was at home gradually i figured out that adapting to the new life is the way i must go the willingness to stay ties to the physical economic institutional and sociocultural aspects of mobile vulnerability that older migrants experience the adaptation process reflects the role of agency in developing coping strategies for meeting the challenges related to migration which also affects older migrants mobile vulnerability discussion this case study on mobility among rural to urban older migrants demonstrates how the proposed conceptual framework is valuable for future study certain elements of our findings confirm previous results of other studies studies conducted in guangzhou and dalian showed that many older migrants moved to cities to provide care for the grandchildren and help with the housework for the adult children 55 they remain highly dependent on their adult children in the new environment in terms of finances housing social life and prospects to return the restricted social network within the families generates feelings of loneliness and social exclusion in the new living environment and increases their social vulnerability 56 these findings were also reported by studies on the zero generation in the transnational migration among international migration in the older age 1557 however in the chinese context many older migrants mentioned that they can manage to live with their adult children if their childrens family needs their support even though they have faced difficulties in adapting to the new living environment this is the representation of responsibilities of older parents in the household according to the traditional chinese culture even though they face various forms of mobile vulnerability postmigration the older parents offer help for childcare and housework when they are the youngold and the adult children provide care support for them in compensation as their parents get old and need family care 58 some of our findings however show differences compared to other studies for example meng et al found that most of the older migrants were satisfied with the physical and sociocultural environment the neighborhoods in which they live and health care services in beijing 11 more than 70 percent of the older migrants were willing to stay in beijing the findings from meng et al differ from the results of this study where most of the participants discussed their dissatisfaction with the high cost of health care services in beijing many of them reported they would plan to move back to their hometowns as they grow older 11 one potential explanation of this difference is that the participants in the study conducted by meng et al were relatively highly educated had relocated as a couple and had urban household registration which is different from the participants as ruralurban older migrants in this study many ruralurban older migrants are a vulnerable group due to their invisibility especially for those who are unregistered the increase in older migrants in beijing brings many challenges for the megacities to provide care support for the older migrants although governments are making an effort to introduce social welfare reform to provide a safety net for older people with rural household registration health and social benefits are currently tied to the household registration 59 the older migrants relocation to urban areas does not automatically entitle them to oldage pension benefits and care policies and formal arrangements do not address the particular needs of this population 6061 a study by liu and feng suggests that within megacities such as beijing and shanghai there are more stringent standards for granting hukou due to a desire to attract wealthier more educated migrants consequently older migrants are often concentrated on the peripheries of cities with limited ability to access social benefits services and welfare during their reconstruction of identity in the new urban environment the materials and power relations structured in the urban environment make the older migrants marginalized in communicating with the local people and socioculturally embedded in their destinations improving the community services in the megacities will help the older migrants reconstruct their social support network and promote their communication with the local people 3 while the length of time that some of the participants had been resident in beijing suggests that to some extent they are ageing in place our findings indicate that beijing was not the place where they were likely to age with a high quality of life our study demonstrated that many older migrants plan to move back to their hometown whether they are willing to do so or they are forced to go back due to the mobile vulnerability they experience consequently care for older people in rural china will face many challenges as a result of the proportionally larger number of elderly residents and the lack of options for care 61 to address the increasing future challenges and improve older migrants vulnerabilities actions should be taken at the macro meso and micro levels at the macro level national policies on social welfare should continue to be improved to mitigating older migrants vulnerabilities policies on the provision of social welfare benefits should take into account the needs of older migrants and be universal to cover the older population based on their age instead of their hukou the meso level captures community and family networks and resources to support care and other needs in older age for example at the community level beijing municipal government requires the migrants to register at the street office for temporary residence permits in the future older migrants need can be evaluated at the community level after their registration the provision of community services can also be tailored based on the individual needs of older migrants the micro level refers more specifically to individual factors such as improvement and adaptation of the migration experience socioeconomic level health condition and active attitude towards ageing of older migrants these findings suggest that social policies should address older migrants needs in a differentiated manner and target the most vulnerable groups in specific ways 15 the small sample size of this study is a limitation additionally the recruitment strategy used where participants were recruited in public space suggests that the participants interviewed may be more physically and socially mobile than other ruralurban migrants as a result this study cannot be considered representative of ruralurban older migrants however the findings of this study help understanding the mobility and vulnerability of this distinct and increasing population group conclusions this study draws on a new conceptual framework of mobile vulnerability influenced by physical economic institutional social and cultural mobility to understand older people experiences of migration from rural to urban areas the rapid socioeconomic growth after the economic reform in china in the late 1970s has affected peoples mobility in various ways physical mobility improves with better access to public transportation system the change from the centrally planned economy following the soviet union model to the market oriented economy for improving the productive efficiency since the late 1970s has created many job opportunities in urban china which improves economic mobility for the migrants however the implementation of the onechild policy for family control in the same period as the economic reform has decreased both household size and family care resources these outcomes affect peoples mobility in institutional ways together with the different rural and urban social welfare benefits tied to the household registration a large number of labor workforce migrate from rural china to urban china either for jobs or for education and stay in urban china after receiving education the increasing migration of workingage adults to urban regions has dramatically altered the traditional patterns of coresident living arrangements and intergenerational support for rural older people as a result the weakening of traditional patterns increases the numbers of older adults living alone and decreases quality of life and support for older parents living in rural areas 62 consequently the older parents of the young migrants also move to urban areas the majority of them migrate for care resources either providing care for their grandchildren or receiving care from their adult children a small proportion of the older migrants move for economic factors the traditional cultural norms are gradually changing to adapt to these rapid socioeconomic changes in china such as a lessened expectation on instrumental care support from adult children due to increased distance or busy schedules and the change relating to older peoples level of authority in the household due to the vulnerable socioeconomic status of the older migrants who are coresiding with their adult children these sociocultural changes enhance the mobile vulnerabilities that the older migrants experience meanwhile older migrants have limited access to the pension and health care insurance and enjoy less welfare benefits in their urban destination due to the lack of urban hukou the vulnerability in institutional mobility created by the hukou system also affects their economic mobility while this study focuses on china many aspects of the research such as the implication of promoting active ageing at the individual level developing community services at the local level and providing a safety net at the national level to improve quality of life for the older migrants may also be relevant in the context of mobility to other countries the results help provide evidence for future planning and policy making in the future more research on the structural improvements and adaptation for older migrants living in megacities in china is required

along with the rapid urbanization process in beijing china the number of older ruralurban migrants is increasing this study aims to understand how chinese ruralurban migration in older age is influenced by and impacts on the migrants mobilities this study draws on a new conceptual framework of mobile vulnerability influenced by physical economic institutional social and cultural mobility to understand older people experiences of migration from rural to urban areas fortyfive structured indepth interviews with older ruralurban migrants aged 55 and over were undertaken in four study sites in beijing using the constant comparative method results demonstrate that rural household registration hukou is an important factor that restricts rural older migrants institutional mobility as older migrants physical mobility declines their mobile vulnerability increases economic mobility is the key factor that influences their intention to stay in beijing older migrants also described coping strategies to improve their sociocultural mobility postmigration these findings will inform service planning for older ruralurban migrants aimed at maintaining their health and wellbeing

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introduction obesity is an emergent global health concern documented in most countries after 1975 1 the etiology of obesity is complex ranging from individual biological and historical factors to social and environmental determinants of health 2 this health condition is related to diabetes cardiovascular disease some cancers obstructive sleep apnea and osteoarthritis according to the world health organization the probability of comorbidities increases with a bmi of ≥250 kgm 2 a measure of body composition for the adult population based on weight and height 3 worldwide in 2014 the prevalence of adult obesity was 13 a figure that tripled in men and doubled in women over the last four decades 1 furthermore some regions experience the double burden of malnutrition 4 even though undernutrition declined since 1990 certain energy and nutrient deficiencies persist 14 hunger is estimated to affect 800 million people and 23 of children ≤5 born in localities with inadequate sources of clean water sanitation and food struggle with restricted growth 4 if these conditions are present in critical periods of human development they may further progress into the intergenerational transmission of malnutrition and have consequences in terms of educational achievements 5 the energy content and nutritional quality of diets demonstrate trends in food choice interrelated in obesity and nutrient deficiencies 67 in 2010 low intakes of fruits vegetables whole grains nuts and seeds had a higher contribution to the global burden of disease compared to the adult prevalence of excess weight 7 studies of dietary patterns in canada the united states and brazil suggest a global shift towards ultraprocessed food products that result in reduced dietary contents of fiber protein and vitamins and minerals and increased contents of fat and sugar 8 9 10 another key behavioral risk factor involved in malnutrition is physical inactivity most prevalent in cities 711 in response public nutrition and health research produced ecological models of obesity 12 13 14 15 for example in 1999 two articles used the terms obesogenic environment and toxic environment to describe characteristics in cities and patterns in behaviors that explain the emergence of the obesity epidemic 1213 the complex nature of these coevolving macroand microstructures is captured by principles and tools from systems science that can be applied to communitybased studies of food and nutrition security 16 17 18 19 food and nutrition security exist when all people at all times have physical and economic access to sufficient safe and nutritious food to meet their dietary needs and food preferences for an active and healthy life 20 this scenario is uncommon in practice because it requires coordination in the activities of agriculture food health and environmental systems that shape individual decisionmaking processes and nutrition outcomes 16 according to the us institute of medicine a food system commonly represented as a supply chain is configured by interdependent and dynamic processes heterogeneous autonomous agents and shared structures between agents 18 given the broad domains and dimensions of food systems in this case study we focus on distribution and consumption processes of an underserved consumer population to understand the social environment of food and nutrition insecurity in the following sections we describe the framework that guides this research in consideration to an identified gap in food environment studies followed by a literature review of food environment research in mexico and the description of the case study in hermosillo city a tool to assess food systems for nutrition security nutrition security is a framework based on community studies aimed to identify the determinants of nutrition 2122 it assumes stable access to sufficient innocuous and nutritious food health care and sanitation and information that in conjunction allow selfcareoriented behavior for health protection it serves as an assessment guide that goes beyond the individual level extending to structural factors in 2013 fao enlisted 30 indicators of food and health supplies that are interrelated with nutritional processes and outcomes 23 these cover broad contextual factors including availability accessibility affordability and stability of food which are key concepts in food environment frameworks 14152425 the food environment refers to the food available to people in their surroundings as they go about in their daily lives and the nutritional quality safety price convenience labelling and promotion of these foods 25 researchers in the field are increasingly using geographic information systems to characterize the distribution and type of food stores and restaurants in specified areas 2426 however assumptions of these models may be faulty because proximity to stores does not account for travel patterns taste preferences social norms about where to procure food or ability to afford foods 26 this was reported by lytle and sokol who revised 432 articles on quantitative measures of the food environment published between 2007 and 2015 a useful comprehensive review on qualitative studies captures this existing gap 27 the limitation of geographical analysis in environmental research and health behavior leads to other proposals focused on individual activity patterns aimed to find key interactions between structural features and consumer food choice 2829 for example in denmark lyseen et al tracked 187 adults aged 1623 using a gps device for a week to test the validity of generalizations based on studies using neighborhood or district areas made available by state agencies the authors discuss that even if people share community school or workplace individual behavior is diverse 87 of the participants traveled outside their home neighborhood to attend schools and 15 of mobility occurred outside of measured home and school neighborhoods 28 furthermore each environment is influenced by unique geographic biophysical cultural and economic systems 18 and as such represents the space linking particular food systems and diets 25 from a systems science perspective an innovative computational technique that can be used to generate simulations of social processes involved in the dynamics of malnutrition is agentbased modeling 16 agentbased models simulate both behavior and contextual factors to understandpredict patterns observable in complex social systems 161730 even though the intent is not to construct an agentbased model we make use of an organization tool developed within the field of abm the parte framework to identify food system structure and activity in relation to nutrition security 17 an initial step is the specification of properties actions and rules of agents and time and environment of context relevant to the system under study properties refer to agent characteristics such as age and health status actions in food systems would include food selection production distribution and consumption rules are consumer strategies and belief systems involved in food decisionmaking processes time and environment depend on research questions and experiment design food environment case study hermosillo city mexico is challenged by the double burden of malnutrition on the one hand overweight and obesity are estimated to affect 70 of adults aged ≥20 and 34 of schoolage children 3132 in agreement with global trends between 1988 and 2006 the prevalence of obesity in women increased from 95 to 34 31 it is also estimated that 35 million women and 28 million men have diabetes 33 in fact as of 14 november 2016 obesity and diabetes called for a nationwide epidemiological emergency 34 on the other hand 13 of children ≤5 are stunted a prominent problem in rural and indigenous localities where this estimate rises to 27 31 maize wheat rice and other cereals are basic foods that provide 32 of the total energy in the average diet however 26 is attributed to the consumption of sweet bread deepfried corn snacks sugary drinks and other nonessential foods while 6 comes from vegetables and fruits 35 this type of dietary pattern contains less fiber vitamins minerals and phytochemicals involved in biological systems that are protective for health 91036 two fiscal policies directed to shape the consumption of energydense snacks and sugarsweetened beverages were implemented in 2014 37 a strategy that targets the consumption of widely available foods independent of region or setting over the last 70 years the food distribution system transitioned from traditional markets to the expansion of supermarkets convenience stores fast food chains and specialty stores changes in the retail environment occurred especially after 1980 3839 an illustrative example is the integration between multinational company walmart and mexican grupo cifra in 1991 by 2012 the commercial enterprise operated 1140 stores in 230 localities covering 60 of consumer demand in urban areas 39 previous research has highlighted that supermarkets convenience stores and fast food outlets cluster around main avenues or federal roads and shopping centers usually not in highpoverty areas leading to disparities in access to these establishments in metropolitan areas 40 in contrast the food environment for underserved populations is characterized by greater availability of corner stores offering a stable supply of ultraprocessed foodssnacks and specialty outlets selling traditional products 41 several studies suggest that limited access to fruits and vegetables stable product availability and food acceptability are important system drivers of consumption patterns for lowincome populations 41 42 43 44 in mazatlán sinaloa lowincome neighborhoods were described as food swamps compared to highincome areas because people are exposed to more ultraprocessed foods 41 in cuernavaca morelos and guadalajara jalisco the food environment around public schools was characterized by higher availability of street vendors offering unhealthy food compared to the food environment around private schools 42 in tijuana baja california a dietary assessment for 2345 women showed variance in dietary patterns in relation to income and education in lowincome women a diet based on maize rice and beans was more prevalent while women in the highincome group tended to eat more vegetables fruits and whole grains 43 the latter results are similar to a study that used nationally representative data from 2006 in which patterns based on maize and beans correlated with lower bmi in adults while the consumption of vegetables was found to be more common in women of older age 44 furthermore there are regional differences in nutrition and dietary patterns across the country in northern states the highest prevalence of obesity in adults is reported compared to central and southern regions 32 the highest energy intakes of sugarsweetened beverages and animal products and the lowest intakes of fruits and vegetables are also reported in northern states 3235 in contrast some southern states experience high social marginalization and distinct nutritional outcomes 31 in particular in the northern state of sonora known for agricultural region yaqui valley the home of the green revolution for wheat 45 it was previously reported that the prevalence of obesity in women who migrate for work in agricultural fields from oaxaca veracruz and guerrero is greater after four years of residence compared to women with less time in the region 46 therefore given the high prevalence of obesity and the differences in dietary patterns it represents an example of an obesogenic environment for transition populations the case study is based in hermosillo city which is located 179 miles from the usamexico border and has a population of 812229 people estimated life expectancy is 727 years for men and 786 years for women 47 and the main causes of disability and premature death are ischemic heart disease diabetes and chronic kidney disease 48 materials and methods general design and procedures in this case study datasets from mexican agency inegi were used to examine the distribution of food establishments in hermosillo 49 we report a qualitative and spatial analysis of regional and national food networks by marginalization degree assigned to basic geostatistical areas we used the social marginalization index developed by conapo it contains nine items of social deprivation in relation to housing education social security income and population density 50 an ageb is the second smallest census unit composed of 150 neighborhood blocks each containing aggregated data for 190 sociodemographic indicators a total of 410 ageb classified in one of five degrees of social marginalization 38 very low 201 low 168 medium 36 high 32 very high and 173 had no available information from april to june 2018 fieldwork followed in two neighborhoods with a very high degree of social marginalization to assess measures of nutrition security dietary patterns nutrition status household food security and perceived food environment and behavior inperson questionnaires and anthropometric data were collected by trained personnel in accordance with the declaration of helsinki the study protocol was approved by the institutional review board at centro de investigación en alimentación y desarrollo and the informed consent procedure followed the mexican norm for human subjects research distribution of food establishments food establishment information was obtained from inegi geostatistical system denue last updated march 2018 49 from a database of 9590 registers of economic units in hermosillo commercial food networks were selected for analysis specifically we included grocery stores from regional food chains and supermarkets convenience stores and beer stores from national food chains food chains operated nationwide were previously identified in research on the evolution of the commercial food distribution system in mexico 39 spatial analysis was done in qgis 323 fieldwork materials inperson questionnaires included a single 24hour dietary recall a household food security scale and a perceived food environment and behavior survey described below the 24hour dietary recall technique involved an interviewer asking the participant to describe all food and drink consumed in the 24hour period before the interview including portion size and recipes following the fivestep multipass method 57 portion size was treated as grams and nutrient composition of each food was collected from a regional food database 58 we used a household food security scale developed and validated for the northern region of mexico similar in format to the household food insecurity access scale and the latin american and caribbean food security scale to capture household and individual access to food as well as emotional perceptions streaming from food deprivation 5960 the number of affirmative answers was used to categorize households in food security or food insecurity food insecurity progresses from perceived stress and anxiety related to poor diet quality affecting preferences and dietary diversity to the reduction of diet quality and quantity among household members to physical symptoms of hunger in extreme poverty conditions an adaptation of the perceived nutrition environment measures survey was used to study the perception of the local food environment and food shopping behavior glanz and colleagues designed four instruments to measure structural factors in defined scenarios and a nonobservational survey to capture the individuals perspective on the food environment 1461 we used a shorter version of nemsp focused on food shopping behavior questions included for analysis were who shops for food consumed at home where do you shop for food consumed at home how often do you visit each of these stores anthropometry was measured to estimate body composition and nutrition status the equipment used was a standing electronic scale a portable stadiometer and a measuring tape during measurement participants wore light clothes an examiner helped position the participant and an assistant recorded weight height and waist circumference nutrition status was assessed estimating bmi in reference to who low weight 185 normal weight 1849 and 25 overweight 249 and 30 obesity 299 62 abdominal obesity was defined as wc 79 cm in accordance with the mexican norm nom043ssa22012 other variables collected using a sociodemographic questionnaire included age education employment housing and kitchen conditions access to social security time of residence in neighborhood and participation on food assistance programs fieldwork data analysis descriptive individual and household characteristics were analyzed in ncss statistical software 1209 to analyze dietary patterns total energy protein fat carbohydrate and fiber were estimated a list of 210 food items were categorized in one of 10 food groups using the macronutrient content informed by an educational guideline for mexican nutritionists 63 thirteen items reported as recipes were broken down into basic ingredients food groups were vegetables fruits cereals and tubers legumes animal products milk and dairy oils and fats sugar and sugary drinks high added fatsugar products ingredients with no energy content the contribution of each group to total dietary energy is reported the analysis followed procedures described in previous research on mexican dietary patterns 3564 results and discussion distribution of food establishments in hermosillo city figure 3 showed the categories of food establishments included for analysis the selection of grocery stores supermarkets convenience stores and beer deposits from a database that included restaurants corner stores specialty stores informal food stands and other types of economic units registered in inegi denue was based on two criteria that facilitated the identification of establishments belonging to large commercial networks namely business name and class of economic activity out of the 760 food establishments 90 of grocery stores 93 of supermarkets 92 of convenience stores and 98 of beer deposits were distributed in areas with low or medium levels of social marginalization none of these establishments were found in the most marginalized areas whereas 54 concentrated in the least marginalized areas in areas with a high degree of marginalization we identified one grocery store four convenience stores and two beer deposits this may be explained by the population density in areas with very high and high levels of marginalization which represented 52 of the total population in the city in 2010 50 there was also a higher frequency of regional grocery stores compared to supermarkets operated by national chains walmart soriana and casa ley even when the latter have expanded their consumer markets since 2008 with the introduction of lowprice neighborhood stores in mexico 39 20 high 1 0 4 2 very high 0 0 0 0 unclassified 71 figures 4 and5 showed the distribution of social marginalization and a qualitative spatial analysis of commercial food establishments in hermosillo patterns of segregation can be observed all of the underserved neighborhoods were found in the periphery of the city as discussed above the analyzed food stores were visibly concentrated in the least marginalized areas previous research in northeastern city monterrey nuevo leon reported a high concentration of fast food restaurants supermarkets and convenience stores in main avenues federal roads and inside of shopping centers established outside of highpoverty polygons 40 other studies provide evidence for disparities in food distribution systems within and between regions 6566 a countrywide study in new zealand documented a higher availability of fast food take out restaurants convenience stores and supermarkets in highpoverty zones compared to lowpoverty zones 65 in the united states a retrospective longitudinal analysis of the food environment in massachusetts reported that unequal access to fast food restaurants remained stable during the last four decades in lowincome neighborhoods in comparison to highincome areas in which access to fast food increased progressively throughout the years 66 thus our results further the discussion on the characteristic heterogeneity of food systems previously described as complex and adaptive 18 by providing explanatory inputs for the contradictory results between analytical studies based on food environment and nutrition measures 2426 an example of contradictory analytical results in current food environment studies was reported by barrera et al 42 in their study of food establishments around private and public elementary schools and the nutrition status of children attending those schools the authors detected a statistical positive relationship between number of mobile food vendors and childrens bmi based on this association a higher bmi in children exposed to more mobile vendors outside of schools was expected however although the number of mobile vendors was statistically higher around public schools there was no statistical difference between the childrens bmi attending public and private schools as discussed by lytle and sokol the identification of key mediating individual and social factors within proximate settings is needed to improve construct validity between food environment measures and health outcomes 26 in this context the recognition of variability in environmental exposures and activity patterns has methodological implications 17 nutrition security of women in underserved neighborhoods in the assessment of dietary patterns estimated average total energy intake was 13201 ± 7241 kcalparticipant energy derived from the mean intake of 455 ± 338 g of protein 483 ± 334 g of fat and 1818 ± 977 g of carbohydrates while fiber consumption was 183 ± 149 g in reference to the nutrition guidelines on the macronutrient composition of diets for healthy adults the contribution of fat to total energy is slightly high at 317 while carbohydrate and protein are within the recommended intervals at 552 and 131 respectively 67 tortillas bread potatoes rice and other cereals contributed 3242 of total energy derived from foods followed by animal products sugar and sugary beverages ultraprocessed foods with high added fatsugar beans lentils and chickpeas oils and fats milk and yogurt fruits and vegetables the dietary analysis showed a high consumption of nonessential foods the combined proportion of sugar sugarsweetened beverages and high added fat and sugar products contributed 245 of total energy in addition the foods most frequently reported were flour tortillas maize tortillas sugarsweetened beverages beans and table sugar according to bojorquez et al the foods in this type of dietary pattern provide high energy at low economic cost for lowincome women in tijuana baja california 43 however in 2006 this diet was more prevalent in rural areas compared to urban areas in mexico 44 the global increases in prices of vegetables and fruits during the last two decades may play a role in accessibility perception to these specific foods and in the overall nutritional quality of diets for marginalized groups in hermosillo 68 furthermore the protein intake suggests a sharp decrease from 72 gd reported in the 1998 sonoran state food basket study 69 in this respect a dietary analysis based on one 24hdr does not provide the whole picture of habitual food practices 57 in agreement with the dietary analysis other studies show that fiber consumption of women in mexico is lower than the recommendation set at 25 gd 67 in 2012 average fiber intake in lowincome women was 24 gd and 19 gd in urban areas 70 we emphasize fiber consumption because it reflects the quality of cereals in the diet and also because the absorption of phenolic compounds proven to be beneficial for gut microbiota health depends on the structural matrix of whole grains in other words the fiber content in cereals may affect the supply of antioxidants necessary for basic functions in the digestive system 71 the nutrition assessment based on wc indicates that 207 of the participants are at lower risk of developing disease related to body visceral adipose tissue however 793 have abdominal obesity a proportion comparable to the national prevalence of overweight and obesity based on bmi reported at 722 in 2016 32 in adult women the likelihood of developing diabetes and cardiovascular disease increases with a bmi ≥ 250 kgm 2 however 58 of the participants have access to limited primary health care in addition 18 of the participants perceived having an adequate access to the food supply while 821 perceived food insecurity an indicator of the availability accessibility and acceptability of foods consumed at home in contrast with the body composition results 179 said members within the household experienced hunger some time during the month before the interview an equal number of participants reported not having access to sewer services and 90 do not have a refrigerator at home both of these facts are useful to comprehend the socioeconomic environments underlying the common experience of hunger in scenarios in which a high prevalence of women have obesity the results of the perceived food environment and behavior survey indicate that physical access to supermarkets grocery stores convenience stores and beer stores affects consumer behavior because 49 reported walking for grocery shopping 41 when asked about the frequency of food shopping 448 said they visited supermarkets or grocery stores once a week and 64 visited neighborhood corner stores 47 days a week these types of food establishments offer a stable and diverse supply of snack foods sugarsweetened beverages and other nonessential ultraprocessed foods 415372 seemingly these may be common consumption strategies in underserved populations given that 73 of the participants mentioned visiting 34 stores for grocery shopping qualitative studies of the food environment indicate that consumers make purchases in multiple stores in consideration of perceived food prices and preferences 27 since most of the participants reported shopping in neighborhood corner stores frequently more than in commercial food retailers food access in terms of distance and transportation is an important environmental factor involved in food decisionmaking processes of marginalized populations the walkability factor was also identified in a review by pitt et al 27 based on this results we also suggest that recognizing the multisectorial multiscale nature of local food systems can lead to tailored community programs that target specific community needs involving consumers store owners policymakers and local farmers as has been the case for the national school feeding program in brazil 73 limitations and future directions this study had several limitations specifically food establishment data obtained from inegi were not physically validated field observations indicate that the locationoperation of economic units may not be uptodate in geostatistical system denue we suggest corroborating the data with other datasets or direct field observations in attention to this problem a research strategy used in a study by sushil et al was to validate food establishment data with the google geocoding application and by directly contacting a subsample of retailers to verify the address and physical location 65 future studies may benefit from the integration of food and nutrition security frameworks with systems science tools as it provides useful insights for research designs on food environments and nutrition outcomes the next step in the construction of a model of a food system would be to consider field methods that capture rules involved in individual decisionmaking processes we also suggest taking a positive deviance approach in which the case study focus are outliers to identify consumer strategies that can be replicated by other community members conclusions in hermosillo the majority of grocery stores supermarkets convenience stores and beer deposits operated by commercial regional and national food networks were distributed in areas with low marginalization levels the variability in the food supply may be interrelated with accessibility and acceptability factors that explain dietary patterns high in fat and sugar and low in fruits vegetables and other antioxidantand fiberrich food sources an overview of the food environment emphasizes the need to identify key features susceptible to change and with the capacity to influence populations on a massive level without producing unintended effects beyond the unique fiscal policies already implemented in mexico and other countries furthermore the turn of public nutrition towards food labeling and other informationbased programs may be overlooking the needs of underserved populations in this context unequal access to food and health supplies underlying the obesity epidemic and nutritional deficiencies should be accounted for in nutrition security research appendix a obesogenic environment case study from a food and nutrition security perspective hermosillo city

obesity and certain nutritional deficiencies are global health problems that emerge in systems of interdependent individual biological and historical factors and social environmental determinants of health nutrition security is a framework that assumes stable access to sufficient innocuous and nutritious food ie food security health care and sanitation and information that in conjunction allows selfcareoriented behavior for health protection to understand the social environment of nutrition insecurity the object of study was the food distribution and consumption system of a marginalized community in hermosillo mexico we assessed the distribution of food establishments by social marginalization level in basic geostatistical areas and the nutrition security status of women in underserved neighborhoods we found that in hermosillo 90 of food establishments included for analysis grocery stores supermarkets convenience stores and beer deposits were distributed outside of areas with high levels of social marginalization the nutrition security assessment suggests that low intakes of fruit and vegetables and high intakes of fat and sugar may be associated with food accessibility and acceptability factors in individual decisionmaking processes future research should take into account the variability of food system environments and address the particular needs of communities in terms of food and nutrition security

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background swaziland is a small nation in southern africa with the worlds highest hiv prevalence 32 of adults between the ages of 18 and 49 are currently living with the virus 1 at national antenatal clinic sentinel surveillance sites this number peaks at 538 of women aged 3034 2 while hiv incidence has leveled off in recent years the burden of disease remains high for a nation of just over one million people 3 twothirds of swazis live below the national poverty line of 125 per day the unemployment rate is approximately 28 and nearly one in four swazis required some form of food aid from the world food programme in 2011 45 inequality is widespread in the country the top 10 of the population earns 40 of the national income while the lowest 10 earns just 17 6 in 2011 swaziland received a lower than expected amount of revenue from the south african customs union resulting in a severe financial crisis in which escalating food prices were a point of international concern 67 legal inequality exacerbates the gendered nature of poverty in the country as recently as 2007 sexual assault was not illegal in swaziland and women could not own property under customary law 8 the government has recently enacted laws to combat gender based violence and to allow women to inherit and own property upon the death of their spouse but these laws are only sporadically enforced 48 after a prolonged lawsuit a court hearing in july of 2013 ruled that according to swazi law a married woman could own her own property but that her husband was still her legal guardian and must represent her in legal proceedings 9 the physical and social burdens of poverty and unemployment disproportionately affect women in the nation 4 1011 in southern africa food insecurity has been linked to an increased risk of hiv acquisition and difficulty remaining healthy for people living with hiv 12 13 14 15 food insecurity has been linked to high risk sexual practices among women including sex work transactional sex and decreased condom use 101215 increased reliance on social networks for food and monetary resources 16 and decreased adherence to antiretroviral therapy 17 consequently malnutrition appears to correlate with both increased susceptibility to hiv acquisition and more rapid disease progression 1218 in addition to the adverse effects associated with taking the medication on an empty stomach art may be less effective at sustaining cd4 levels among individuals who are suffering from malnutrition or food insecurity 12 plhiv are frequently advised to eat healthy foods by health promotion campaigns and health care workers 19 however some studies have demonstrated that plhiv sometimes must choose between paying for food and paying for art 17 even when art is provided free of cost by government or other health care organizations as is the case in swaziland the time and money costs of transportation to the clinic may create barriers to art adherence 14172021 in southern africa formal sex work and transactional sex are sometimes conflated both practices involve the exchange of material goods for sex but formal sex work is characterized by self and community identification as a sex worker whereas women who engage in transactional sex do not identify as sex workers and their relationships tend to be socially sanctioned or at least tolerated 22 23 24 as in other countries in subsaharan africa there is some debate about the actual legal status of sex work in swaziland but for practical purposes it is de facto illegal and highly stigmatized and women who practice streetbased sex work experience frequent police harassment in the form of rape blackmail intimidation and arrest 25 26 27 limited research has been conducted on the nature of sex work in swaziland one rapid mixed method assessment commissioned by the ministry of health and the national emergency response council on hivaids focused on describing the hiv related knowledge attitudes and practices of 53 female and 8 male sex workers who were interviewed throughout the country 25 this study found that sex workers were frequently driven by poverty and high unemployment but that some women also saw it as a viable alternative to the legal and economic disadvantages of marriage a quantitative study conducted with 327 female sex workers in conjunction with this project found an hiv prevalence of 605 and that consistent condom use was less common with regular clients and nonpaying partners as compared to new clients 2829 though heterosexual sex is the main mode of transmission in swaziland and sex workers are considered a most at risk population both internationally and in the country 30 we could identify no studies besides the previously cited examples in either the peerreviewed or grey literatures which focused on the needs of female sex workers who are currently living with hiv in swaziland our study objective was to examine the hiv prevention care and treatment needs of female sex workers who are living with hiv in swaziland we focused our study using a positive health dignity and prevention framework phdp is an approach to support for plhiv that emphasizes four main support goals maintaining the physical health of plhiv maintaining the mental health of plhiv preventing further transmission of hiv and involving plhiv in the process of research advocacy and care 31 methods setting and participants after consulting with key informants within the swaziland moh nercha the swaziland national aids program and ngos which provide services to sex workers in the country we focused our research in four different regions a rural border town where most sex work focuses on truck drivers making their way to or from south africa a periurban community where most of the women we spoke with sold sex in bars and clubs and two sites located in the urban manzinimbabane corridor most sex work in the manzinimbabane corridor is streetbased although some women also work in bars our inclusion criteria required that informants were over the age of 18 reported that they had been previously diagnosed with hiv and sold sex other research in the region has demonstrated that the line between sex work transactional sex and financial support within a romantic relationship can be blurry and is largely based on the context and subjective perspective of the women involved 32 33 34 to account for this our criterion for sex work was selfidentification as a sex worker although we had no exclusion criteria based on the last time a woman had sold sex most participants were actively engaged in sex work at the time of data collection participants were recruited through support groups and peer education networks run by government public health clinics and local ngos ngo staff and public health nurses who worked closely with these groups were asked to refer women who were living with hiv to the study staff if potential participants expressed interest they were invited by the referring ngo staff member or nurse to meet the study staff at a prearranged interview location further participants were then recruited using snowball sampling methods 35 community engagement and ethical considerations a community advisory committee of sex workers with representation from all four geographic areas was created to advise the study and ensure that study questions and procedures were acceptable and welcomed by the sex work community in addition the first author made frequent visits to each of the four sites these visits were used to hold meetings that explained the study to potential informants ensure that the study was acceptable hear potential concerns and modify any study procedures that the community found objectionable meetings were conducted largely in siswati with occasional translations to or from english in addition to a staff member from either the moh or population services international who had experience working with sex worker populations in the country a member of the sponsoring ngo or public health unit whom the members trusted was always present at these meetings rfm spoke with these group leaders before and after meetings to learn if new concerns had been raised and ensure that the study remained welcome to the community the study received ethical approval from the swaziland ministry of healths scientific ethics committee and the johns hopkins bloomberg school of public health institutional review board data collection and analysis two young swazi women who were fluent in both siswati and english conducted interviews with sex workers rfm conducted key informant interviews and one english language sex worker interview interviewers were trained in qualitative research methods ethical considerations and the special sensitivity concerns presented by the study topic matter and informant population members of the community advisory committee were included on the hiring committee for these interviewers a total of twenty participants were recruited evenly across all four sites participants ranged in age from 18 to 43 the median age was 28 the final sample size was determined first by ensuring that all sample sites were equally represented and then through iterative analyses throughout data collection that allowed the study team to reasonably conclude that data saturation had been achieved after the twentieth informant was interviewed two semistructured indepth interviews were conducted with each participant generally with one week between interviews in order to build rapport and revisit important themes 35 interview guides were designed to elicit informants stories about their lives as sex workers and as plhiv interviews ranged from 30 to 90 minutes and were held in private offices which belonged to the local ngo or public health unit or which had been reserved for the occasion verbal informed consent was obtained for each participant in siswati or english depending on the participants language preference participants were reimbursed for their time equivalent to the cost of a meal and travel to the study site all names used in this manuscript are pseudonyms debriefing meetings were held between study staff and interviewers after each interview session larger debriefing meetings were held with the full study team each week these meetings were used to monitor interview quality assess themes as they emerged use initial findings to shape later interview questions and ensure data saturation this iterative approach between data collection and data analysis is a hallmark of qualitative research 35 interviews were transcribed verbatim into siswati and then translated into english the english language transcripts were then coded in atlasti codes were generated based on the debriefing and analysis meetings that had been held throughout the course of data collection results dual themes of hunger and poverty emerged early in the course of data collection and remained salient throughout the process in keeping with the iterative nature of qualitative research as the theme of hunger emerged interviewers were encouraged to probe specifically on how this fit into the lives of our informants during analysis of the transcripts four major themes crystallized hunger and poverty the relationship between sex work and hiv infection the use of food to manage hiv status and the effects of sex worker and plhiv identities on social support these were organized into a concept map that shows a cyclical interaction between hunger sex work hiv status and social support hunger and poverty informants were asked to share their stories of entry into sex work in these narratives hunger was frequently the initial reason for sex work entry entry was often linked with personal or familial poverty and in most cases this poverty manifested as hunger many of our informants had children and described initiating sex work after being left by the father of her child in the face of high unemployment and without male support or the support of their childs paternal family many women described sex work as one of the few avenues available through which they could feed and support themselves their children and sometimes their extended families women described being introduced to sex work by friends or through a slower process of individual experimentation what can i say i wanted to support my child i told myself that i was doing whatever i was doing for my child that is how i started her father was not supporting her he was denying responsibility but then said he was scared… he said a lot of things and asked me not to report the pregnancy as per swazi custom because if his mother would know she would make him quit his studies ok i agreed thinking he would own up to his responsibilities if he went to study i thought he would come see me when he was on his holidays but he decided not to come that is how i started since i had to provide for the child ntombifuthi the father of my child was supporting me until we had some problems and separated… i didnt have money to support my child and my parents were always mad at me… i started crying asking myself what i can do so that i can bring something at home… and i tried to go and hike trucks solicit truck drivers … the truck drivers maybe will come to me and ask can i buy you a drink then after that the person asks me what if we can go and have sex maybe i can give you e50 usd 550 … i started to enjoy because with that fifty rand in the morning i would go and buy bread nonhlanhla my friends i would see them… going every sundown they would bath and go then one day i asked them where they were going they told me that while i sit here they were going to do sex working to support their children paying school fees for their kids with the work they were doing nokuhanya while hunger was a reason for entering sex work few women described themselves as currently food secure hunger and the need to support themselves their children and their families were constant concerns in our informants lives many informants framed this ongoing poverty and hunger within a larger context of high unemployment and an inability to find other means of supporting themselves my aunt and cousin know my hiv status but they come to me for their plaiting hair braiding however i had to supplement that money so to feed my children because i thought what if i have no customer that day what am i going to do… there was nothing i would do really because i had to buy food for my children for they would call to tell me food is finished phila food to manage hiv status our informants were frequently advised at local clinics that they should eat healthy foods to manage their hiv infection this advice was well received and many informants talked about healthy foods when asked how they coped with their hiv status the idea of healthy foods was also frequently mentioned when informants were asked what services could be provided to support them this conversation was multifaceted some women discussed food as a means of hiv management within the broader context of their daily poverty for these informants healthy food was equated with any food in addition to situating this need within their everyday experience of poverty some informants also made a direct link between food and their art medications you dont necessarily have to eat tasty food to take the pills just any food that will settle in the stomach and allow for digestion of the pills because you cannot take the pills on an empty stomach siphokazi some framed this need in the opposite way discussing fears that poverty and an inability to access food might cause them to get sicker this fear was frequently cited to explain an ongoing need to engage in sex work or concerns about violence or a lack of paying customers being needy is the problem because we are poor in this community… sometimes a client doesnt pay me and he threatens to beat you then i leave him be then i dont have anything to eat at home then my cd4 count drops when the person doesnt pay me nokuhanya other women discussed the need for diet change and the integration of more healthy foods as a means of selfcare the term healthy seemed to have diverse meanings but in general it incorporated increased fruit and vegetable consumption decreased alcohol and fat consumption and an increased inclusion of traditional swazi foods into the diet i am able to carry on with my life because they advised me on what to eat at the hospital i eat some fruits and things like spinach pears peanuts i just eat healthy food … i eat pawpaw papaya and the things i am supposed to eat i also eat swazi traditional food nokubonga food was an important part of hiv selfcare for our informants diet was frequently posited as a means of gaining control over health many women seemed to gain a sense of comfort from this even given the precarious nature of their economic status and the difficulty and expense that acquiring healthy foods to comply with their medical advice created for them hiv infection many of our informants believed that they acquired hiv in the context of sex work women understood the potential hazard of hiv reinfection and sometimes used this knowledge to negotiate condom use i tell them my status one once said he had no problem with that i just told him no whats mine is mine… also whats yours is yours lets not worsen each other nokulunga other informants would have preferred to use condoms to reduce their risk but were not always able to enforce condom use male clients often preferred sex without condoms and were willing to pay moreor would only pay at allfor fleshtoflesh sexual intercourse as described by this informant things like hiv people come with a lot of money and tempt you they tell you that they will pay more if you dont use a condom you find that the person will tempt you at the time you need money most because you have no food at home you are putting yourself in great danger at that moment siphokazi other women thought that they had been infected through nonpaying or intimate partners incidents of rape and coerced sex were described frequently although only a few informants explicitly linked these stories to their own hiv acquisition i know how i got it i think i am not that sure but i think i know because i was involved with one policeman from those times when i broke up with the father of my first child i got involved with this policeman and one time i went to his house with my friend and he said i must go and clean for him when we were there i found a book written food for people living with hivaids why he was living with this book and why he was hiding it … i asked him about it and when i looked…food which is in the book was the food which was filled in the fridge i thought this guy has hiv and i asked him about it he said no it was just a book he got from the clinic and that he was not hiding it he did not know how it got under the bed i kept quiet and one day i went to his house for cleaning i cleaned for him it was during then when i was about to leave he came inside and grabbed me i tried to say no i said no i did not want because i was confused about the book and he was sick coughing he used to cough he grabbed me and he had sex with me from that time i knew that if this person is hiv positive then i am positive too some months went by then he died and i knew exactly that he died of aids from that time i told myself that if i can go and check surely they will tell me that i am hiv positive… i continued doing this thing sex work and i got infected so many times because i have been doing it with truck drivers without a condom nonhlanha social support both sex work and hiv are highly stigmatized in swazi society informants tended to deal with these stigmas separately and were often more willing to disclose their hiv status than their occupation however living with hiv was often associated with promiscuity and so it was difficult for informants to totally disentangle the two identities women reported mixed strategies and varied responses from their friends and family in response to disclosure of either their hiv status or their engagement in sex work sex work was rarely disclosed to social network members who were not already part of the sex worker community some informants reported receiving financial assistance from other community members from time to time while others reported widespread distrust among sex workers and fierce competition for clients that sometimes became violent informants assumed that their families would react negatively or treat them poorly if their occupation was revealed some informants reported that their family and friends already suspected or assumed that they were engaged in sex work reactions ranged from tacit though disapproving acceptance of food and financial support that was funded by sex work to outright ostracism informant im afraid to tell them even at home i havent told anyone they once asked me where do i get the money i deceived them that i have a boyfriend who gives me money then im able to help them interviewer those who are asking you they know that youre not working informant its just that i send the money and they wont ask me much winile you see it can happen that some may neglect me like i said at home some are christians if they can hear about this they can neglect me… it is just that now its my life there is no other way i can get money nomthandazo disclosure of hiv status tended to elicit better although still mixed reactions from an informants social network some informants described receiving both material and emotional support from family after revealing their status other informants reported being shamed and excluded by their families or their spouses families and being denied materialespecially foodsupport they treat me well they sometimes buy me things like vegetables my aunt has a garden so she brings me some vegetables they bring me any swazi food they have nokubonga at one point a support group member told us … that she is not welcome at her marital home you see she continued to tell us that she is not given food at her marital home we had to help her by donating some money so she may be able to buy some mealie meal course maize flour for her children phila the same informant reported losing her job and feeling driven back to sex work as a direct result of hiv stigma informant i used to work for one lady in a salon then one day i had gone out to the toilet she opened my bag because i was new in the salon i had not told her anything about my status she would then monitor me because i think she saw the arvs interviewer did she ever see you taking them informant she saw them in my bag when she opened it and she monitors my actions more so when i get cuts then she would tell me not to touch so many things this shows that so many people are not well informed about hiv she monitored everything i did she would also talk bluntly in front of the customers then i opted to stop working when she asked me why i just told her i couldnt work for her anymore i would rather stay at home and get a job i dont know about thats the reason i ended up taking up the job am doing right now because no one judges you there phila in general disclosure of hiv status tended to meet with a better reception than disclosure of sex work but both met with mixed results at best and many of our informants reported fear of disclosure discrimination as a result of the synergistic effects between the dual stigmas of hiv and sex work was less common manifestations of dual stigma were most commonly reported in the health sector although this experience was not universal you find them looking at you as a lesser being there are those whom even if you can explain to them…they believe that when you are positive it is because you have loose morals a person would say that you got hiv because you sleep around yet they dont even know what really happened ntombifuthi discussion we found that sex workers who are living with hiv in swaziland are frequently involved in a cycle of food insecurity hiv risk and social marginalization sex work is used to address food insecurity for women and their families many of our informants attributed their hiv infection to sex work and identified hunger as a motivation to engage in sex without a condom increasing the risk of hiv and sti acquisition for themselves and onward hiv transmission to their clients while sex workers were advised by local health workers to use healthy foods to manage their hiv and to ensure maximum efficacy of art their stigmatized identities of plhiv and sex worker created a reduced ability to rely on social networks for food and monetary resources and an increased reliance on sex work to meet these needs while hunger was not a direct cause of art nonadherence in this sample informants did express anxiety about the effects of taking art on an empty stomach and on the effects hunger would have on their disease progression social networks which our informants may have been able to draw on for material support in the pastfriends and family from back homewere less likely to provide support because of our informants line of work and at times hiv status this social ostracism reinforced reliance on sex work as a means to address food insecurity while informants were more likely to disclose their hiv status than their occupation the stigma surrounding hiv made it difficult for them to totally avoid associations with promiscuity or immorality as in other studies conducted with sex workers in south africa and subsaharan africa poverty and hunger are a large part of the sex work identity expressed by our informants 2236 campbell suggests that emphasizing their own poverty and restricted options beyond sex work may help sex workers reclaim some social respectability and distance themselves from the stigma of the sex work identity 36 this internalization of poverty may reinforce womens drive to compete with one another for resources and clients and make it difficult for sex workers to present a unified front when negotiating safer sex with clients while the lived poverty of our informants was very real the complex links between social support poverty and sex work stigma have implications for communitybased or community organization style interventions in the region phdp services should address the centrality of food insecurity and poverty in the lives and identities of sex workers who are living with hiv in swaziland poverty and hunger were often directly equated and hunger was the most pressing manifestation of poverty in our informants lives sex workers who are living with hiv spoke positively about the clinical advice they had received to eat healthy foods but the definitions of healthy foods ranged from having any food available at all to refraining from alcohol abuse or fried foods to integrating more fruits and vegetables or more traditional swazi foods into their diets future interventions intended to directly impact food insecurity would require careful formative research that addresses local understandings of food insecurity and healthy foods to ensure local appropriateness and desirability managing their infection through a healthy diet was an important hiv coping strategy for many informants food prescription or supplementation programs may be the most direct way to address food insecurity for sex workers who are living with hiv combining food supplementation with nutritional counseling has been found to create greater impact than food supplements alone 1837 and based on our findings this would likely be considered acceptable to this population in kenya a program implemented by the ampath group provides food prescriptions not only to food insecure art patients but to their dependents 38 an important consideration given that many sex workers in swaziland are using sex work to support their children the sixmonth food prescription was coupled with a transition program to microfinance or agricultural training programs for patients and their family coordination with the donor community and investment in the local agricultural economy 38 while the direct provision of food or branded supplements may lead to unintentional disclosure of plhivs status the ampath groups efforts to combine food prescriptions microenterprise and dialogue with community members and international donors holds potential for an empowering community based approach to phdp sex work programming many sex worker interventions tend to focus on individual level strategies that are specific to sex workincluding peer education condom promotion or sti treatmentto decrease hiv transmission from sex worker to client or client to sex worker 39 and neglect the need to reduce structural barriers that may limit the accessibility of testing treatment and adherence services which are targeted to the general population these barriers include criminalization stigma and cost 40 as well as the subordinate social and legal status of women in swaziland and restricted access to education these were all salient factors in our informants lives given the high prevalence of hiv in both the general and sex worker population in swaziland programs designed to improve access for sex workers who are living with hiv to testing treatment and adherence support are important to reduce individual viral load and onward transmission of hiv 329 this type of structural intervention is important for stigmatized populations such as sex workers because they experience barriers to care beyond those normally experienced by plhiv 40 additionally approaches that focus solely on individual level interventions amongst sex workers can create the perception of sex work as a risk vector 40 this may inadvertently potentiate rather than reduce stigma and marginalization the potential for escalation of stigma is important as stigma and decreased social support played a marked role in increasing food insecurity and reliance on sex work amongst our informants community empowerment interventions have shown positive results for hiv related outcomes including reduced hiv prevalence and increased condom use 41 this type of intervention works to enhance sex workers empowerment as a community to address the poverty violence and stigma that heighten sex workers vulnerability to hiv and prioritizes intervention aims that are set by the sex work community themselves 4142 this approach has been successfully implemented in india brazil and the dominican republic but to date there have been no assessments of community empowerment interventions with sex workers in southern africa nor have any of these interventions addressed the specific role of food security and vulnerability to hiv 43 44 45 46 47 48 our own findings and other qualitative work in the region suggests that working to build solidarity and collective action among sex workers may counter some of the stigma and violence experienced by sex workers who are living with hiv and may also improve the feasibility of income generating projects 2649 community empowerment projects must take into account the fact no communitysex work or otherwiseis monolithic for any program to be successful competition for resources between sex workers as well as local politics and history must be taken into account however this approach would allow sex workers with hiv to set their own intervention priorities such as food security and to establish for themselves how they would like to define and address the problem in the long term efforts at the national level to improve womens social legal and economic standingincluding improved access to education and employmentare needed to broaden womens economic options and to reduce the vulnerability of female sex workers 42 in the shorter term economic interventions such as microfinance and microenterprise projects can create an additional income source for sex workers and provide a buffer against financial crises 4250 in india a microenterprise program was found to reduce hiv risk behaviors and provide a feasible and acceptable source of secondary income in a cohort of sex workers 51 an evaluation of a program in cambodia found that job training in hotels was acceptable to a group of former sex workers and the authors emphasized the need to engage employers support networks sexual partners and sex workers themselves for maximum impact 52 odek et al showed that a microfinance program in kenya facilitated by partner organizations that had longstanding relationships with the sex work community resulted in decreased partner numbers and increased condom use amongst regular partners approximately half of the women enrolled in the project opted to suspend sex work after two years of participation in the microfinance program 53 however morbidity amongst participants resulted in a significantly lower loan return rate than is usually observed in successful microcredit programs in subsaharan africa cash transfer interventions have also recently shown promise in reducing hiv risk behavior possibly because they reduce the need to rely on sexual partners for financial security 54 while we are aware of no cash transfer or other social safety net programs in subsaharan africa that targets sex workers who are living with hiv a qualitative study of a cash transfer program in malawi evaluated the effects of the intervention on enrolled plhiv informants reported that the cash transfers improved their individual and household food security and their ability to access healthcare and art there was also a suggestion of decreased social marginalization and an increased ability to take out small loans from community members 55 in south africa national child social grants given to caregivers of children under the age of 18 have been found to increase both household nutritional status and the ability of parents to engage in the broader workforce 56 for sex workers who are living with hiv microcredit microenterprise and conditional cash transfer or social safety net programs all have promise especially given the fact that many of the women we interviewed had entered sex work to provide for their children these types of interventions would likely be most successful if they are designed in partnership with sex workers consider sex workers romantic social and familial networks and include components that focus on the continuing physical and mental health of participants conclusions informants described a cycle of hunger hiv and sex work in which food insecurity frequently prompted sex work sex work in turn generated heightened risk of acquiring hiv which our informants attempted to manage through eating either healthy foods or any food at all in order to manage their infection and prevent side effects from their hiv medication this increased dependence on food created an increased dependence on income generated from sex work moreover the dual identity of sex worker and plhiv created the potential for ostracism from social networks and a decreased ability to rely on family for material assistance based on the complex nature of this cycle interventions that seek to provide phdp services for sex workers living with hiv must address both upstream socioeconomic factors and individual risk behaviors including the roles of poverty and food insecurity in creating vulnerability in swaziland these upstream risk factors include a national recession high unemployment ongoing drought gender inequality and other factors beyond the control of individual sex workers phdp services and interventions for sw which address the pathways through which food insecurity generates vulnerability to hiv and social marginalization build sex workers collective efficacy to mobilize consider individual and family level poverty alleviation and address social and policy level changes are likely to have the greatest success competing interests the authors declare that they have no competing interests

background swaziland has the highest hiv prevalence in the world 32 of adults are currently living with hivand many swazis are chronically food insecurein 2011 one in four swazis required food aid from the world food programme in southern africa food insecurity has been linked to highrisk sexual behaviors difficulty with antiretroviral therapy art adherence higher rates of mothertochild hiv transmission and more rapid hiv progression sex workers in swaziland are a population that is most at risk of hiv little is known about the context and needs of sex workers in swaziland who are living with hiv nor how food insecurity may affect these needs methods indepth interviews were conducted with 20 female sex workers who are living with hiv in swaziland interviews took place in four different regions of the country and were designed to learn about context experiences and health service needs of swazi sex workers results hunger was a major and consistent theme in our informants lives women cited their own hunger or that of their children as the impetus to begin sex work and as a primary motivation to continue to sell sex informants used good nutrition and the ability to access healthy foods as a strategy to manage their hiv infection informants discussed difficulty in adhering to art when faced with the prospect of taking pills on an empty stomach across interviews discussions of cd4 counts and art adherence intertwined with discussions of poverty hunger and healthy foods some sex workers felt that they had greater trouble accessing food through social networks as result of both their hiv status and profession conclusions informants described a risk cycle of hunger sex work and hiv infection the two latter drive an increased need for healthy foods and an alienation from social networks that offer material and emotional support against hunger services and interventions for sex workers which address the pathways through which food insecurity generates vulnerability to hiv and social marginalization build sex workers collective efficacy to mobilize consider poverty alleviation and address social and policy level changes are necessary and likely to have the greatest success

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introduction many things influence scientists productivity one contributing factor is a scientists professional network 1 2 3 4 which has increased in importance as research requires ever more extensive assistance from fellow scientists this assistance may lead to more explicit collaboration and in turn to coauthorships the steady increase in the number of coauthored papers documents the growing reliance on research teams 5 6 7 coauthored papers tend to be published in higher impact journals 87 and are more likely to be cited 910 from this one can infer that coauthored papers tend to be higher quality arguably because more individuals ideas are included and that the higher citation of coauthored publications may reflect the wider readership by reaching each authors personal network in addition certain kinds of research require access to special equipment and related expertise thus increasing collaboration especially in the hard sciences such as the biological and chemical sciences collegial advice another type of scientific collaboration may be provided through for example comments on manuscripts or suggestions on research direction it entails less involvement and yet is still important for knowledge production this type of collaboration is frequently invisible because it does not appear as coauthorship however it is sometimes credited in acknowledgments cronin 11 examined acknowledgments in five prominent information science journals and reported that the number of articles with acknowledgments consistently increased between 1971 and 1999 he concluded that this trend is plausibly a result of reliance on trusted colleagues for feedback and a network of collaborators because both strong and weak scientific collaboration affect a researchers productivity investigating their professional networks can improve understanding of knowledge production advances in information and communication technologies have facilitated scientific collaboration across multiple countries in recent years 12 international collaboration in particular tends to produce highly cited publications 1314 and leads to papers published in respected venues 15 in this paper we address less explicit scientific collaboration and examine egocentric social networks of faculty and graduate students in life sciences in japan singapore and taiwan we asked them to name individuals from whom they received advice and with whom they discussed research the scientists in these three countries have been reported to have high productivity 1617 we sought to identify what factors if any influence the publication productivity of these scientists specifically 1 what factors influence the formation of international ties in the discussion networks and 2 whether and how international ties influence publication productivity social network and productivity the majority of prior studies in this area examined researchers professional networks through coauthorship analysis ie strong collaboration this line of research revealed for example that researchers in a bridging position tend to be more productive 1819 and that researchers who have more coauthors and one frequent primary coauthor tend to score high in productivity 18 using publication records of coauthorship petersen 20 found that two thirds of the collaboration ties were weak lasting less than five years and that a remarkable 6080 of collaboration lasted only one year at the same time petersens study indicated that super ties or extremely strong ties were common including approximately one in 25 researchers networks with these super ties were found to be more productive few studies have looked at researchers social networks that include weak collaboration taba heard brennan lee and lewis 21 investigated professional networks of australian radiologists using egocentric social network analysis in addition to a survey about their professional work the radiologists read a test set of mammograms the study found that strong ties appeared to help radiologists develop better analytical skills specifically to interpret medical images accurately with the combination of bibliometric and egocentric social network data wang 22 found that strong ties positively affect researchers productivity at first but eventually have a negative impact when tie strength becomes too strong in wangs study tie strength was measured by the frequency of collaboration within five years global scientific collaboration scientific collaboration is not limited by geographical boundaries scientists all over the world reach out to their international colleagues and the globalization of scientific collaboration has steadily and significantly increased 1223 waltman et al 12 studied distances separating collaborators on 21 million research publications from various countries and fields of science and found that the average distance was 1553 kilometers in 2009 increased from 334 kilometers in 1990 although collaborations that cross national and geographical boundaries are not easy such scientific collaboration tends to result in higher citation counts than the publications by strictly domestic collaborators according to gla ¨nzel and schubert 13 who studied citation impacts of international coauthorship in chemistry similarly hong and zhao 15 found that chinese scientists with network contacts overseas were more likely to publish papers indexed in the science citation index findings such as these validate government initiatives such as in finland to support globalization in science 14 coccia and wang 24 conducted a longitudinal bibliometric study to examine how international scientific collaboration evolved from 1973 to 2012 they found that international collaboration in physics and mathematics ie basic research fields had declined whereas in biology and clinical medicine ie applied research fields it had increased they also reported that international collaboration had generally increased over time although the percentage of international collaboration with institutions had not changed in other words the basic structure of collaboration in terms of institutional level versus individual level has not altered guerrero bote olmedagomez and de moyaanegon 25 investigated advantages of international collaboration using bibliographic data in the scopus database they found that papers with international collaborators tend to be cited more often than papers with domestic researchers and that in general the higher the number of collaborating countries on an article the more citations it accumulates interestingly the authors noted that the us gains the fewest citations from international collaboration because us institutions already have diverse researchers and rich resources asian countries such as china india south korea and japan tend to produce many publications but overall score lower on the percentage of international collaboration and normalized citations guerrero bote et al 25 speculated that this may be a consequence of persistent language barriers even though these countries are producing more scientific publications prior research shows that both international collaboration and the proportion of foreigners in scientists discussion networks is positively associated with productivity 26 ynalvez and shrum 26 examined the relationship between professional networks scientific collaboration and publication productivity among scientists in research institutions in the philippines graduate training overseas is positively associated with the proportion of a scientists contacts in those countries researchers strong international ties in the former host country can serve as a prerequisite or a driver of international research collaboration which can contribute to publication productivity few studies have examined the formation of social networks themselves in this paper we seek to fill this gap by investigating factors associated with the formation of research discussion networks ie weak collaborations focusing on international ties in the network we refer to a tie as international when scientists discuss research with colleagues living abroad and as domestic when the discussions are with colleagues living in the same country first we ask what makes people choose discussion partners who live abroad rather than in the same country second we ask whether and how the international ties in the discussion network influence productivity methods ethics statement both indiana university irb and texas a m international university irb have approved the study the informed consent form was presented to all participants and written consent was received when participants agreed to respond to the survey and interview questions sample facetoface surveys and indepth semistructured interviews were conducted among a sample of faculty and doctoral students in the life sciences at 10 research institutions in japan singapore and taiwan in each country 30 faculty and 70 doctoral students were interviewed faculty and students were randomly drawn from list frames generated from departmental websites of the target institution the survey questionnaire and interview included questions on research productivity research projects research involvement research discussion network and sociodemographic characteristics questions on the research discussion network employed an egocentric social network design in the form of a name generator with its attendant name interpreter each respondent could nominate up to 10 individuals with whom the ego discussed important matters about research our final sample included a total number of 290 respondents and 1435 network members for each interview session respondents were interviewed in either their native language or english interviews were recorded and lasted about an hour on average measures name generator instruments for egocentric networks surveys have long employed name generator instruments to collect egocentric network data instruments typically include two types of questions name generators that ask the names of people in the respondents social network and name interpreters that ask information on the characteristics of the alters and the relationships between the respondent and alters 2728 in the questionnaire of our study respondents were asked to nominate up to 10 alters whom they talk to go to for advice or who come to them for advice regarding research for each alter the following questions were asked the alters gender nationality location types of relationship between the alter and respondents duration of the relationship and communication mode international ties international ties are measured based on information from a name generator and name interpreter of egos network mentioned above respondents were asked to nominate up to 10 alters with whom they discuss research for each alter there is a question on the alters location and the responses had 10 categories ranging from in the department and in another institution within the country to other countries we collapsed the responses into two categories within the country and outside of the country according to this categorization we created a dummy variable ties with alters living outside of the country are referred to as international ties and coded as 1 and ties with alters living within the country are referred to as domestic ties and coded as 0 this variable was used as the outcome in the multilevel logistic regression models to answer the question about what characteristics of alters ties egos and networks influence the formation of international versus domestic ties research productivity in the questionnaire respondents were asked how many manuscripts they have written in the last 12 months and how many articles they have published in international national and top journals respectively during the last 3 years based on these questions we constructed three variables to measure research productivity 1 the number of manuscripts written in the last 12 months 2 the number of papers published in top journals and 3 the total number of papers published the last two variables were based on the time period from 2007 to the time when the surveys were conducted top journals are defined as journals with an impact factor of at least four these three measures of research productivity were used as the outcomes in the regressions to answer the question of whether and how international ties influence research productivity alters and ties characteristics of alters and ties include the alters gender the egos relationship with the alter the intensity of the discussion how long the ego has known the alter and the mode of communication the mode of communication was inspired by turkle 29 who encouraged attention on different types of communication and whether they require participants to engage in spontaneous interactions rather than mostly relying on asynchronous communication egos and networks characteristics of egos include their sociodemographic attributes such as gender age and marital status for professional attributes we included the percentage of time devoted to research the number of international conferences attended and a dummy variable about graduate training abroad to assess whether the respondent has ever spent time outside of their home country for graduate training measures of network characteristics include network size the percentage of women in the network the percentage of nonconversationalonly modes of communication the percentage of mentormentee relationships the average intensity of discussion in the network and the average length of time for which the ego has known the alter these characteristics are aggregated to characterize ones social networks which is a standard method in egocentric networks research that uses multilevel models 30 analytical strategy we use multilevel logistic regression models to answer the first question what characteristics of egos alters ties and networks are associated with international ties because each respondent or ego reported several relations with alters the egoalter ties are nested within respondents that is the structure of the network data is nested or clustered traditional statistical methods such as regression are not appropriate for data with a hierarchical nesting structure because they assume independence between the ties with ties nested within egos they may not be treated as independent multilevel models are suitable for data with a nested structure 31 the level of the egoalter tie is referred to as level 1 or the lowest level and the level of the ego is referred to as level 2 or the higher level attributes associated with ties and alters are treated as level1 variables and attributes associated with egos are treated as level2 variables the dependent variable in the multilevel logistic regression model is defined at the lowest level or the level of the egoalter tie this study employs a twolevel model to predict the odds that a tie between ego and alter is international rather than domestic a threelevel model in which institutions were included as the third level was examined but the result showed no improvement in the models goodness of fit thus we used only a twolevel model in our analysis the level1 model predicts the odds that a tie between ego i and alter j is international in this model β 0i is the intercept β 1i the slope x ij the values of the level1 variables ie characteristics of alters and ties and ε ij the error term which is assumed to follow a normal distribution with a mean of 0 and a standard deviation of σ the level1 model aims to examine whether and how an international tie between ego and alter is associated with the attributes of alters and ties such as an alters gender and relationship between ego and alter level 1 model log p ij 1 à p ij ¼ b 0i þ b 1i x ij þ ε ij ð11þ ε ij nð0 s 2 þ ð12þ our level2 model is a randomintercept model that is only the intercept is allowed to vary randomly over the egos it shows that the intercept in the level1 model depends on level2 variables ie ego and network characteristics such as an egos gender and the proportion of males in an egos network in this model ego i represents the values of the ego characteristics network i the values of the egocentric network characteristics u 00 the population mean of the intercept and μ 0i the random effect which is assumed to follow a normal distribution with a mean of 0 and a standard deviation of σ μ the slope includes only the fixed effect level 2 model b 0i ¼ g 00 þ g 01 ego i þ a 01 network i þ m 0i ð21þ b 1i ¼ g 10 ð22þ m 0i nð0 s 2 u þ ð23þ this level2 model when combined with the level1 model can be used to examine how an international tie between ego and alter is associated with the attributes of ego and networks as shown in eq 3 what is more all continuous predictors are centered on their grand mean log p ae 1 à p ae ¼ g 00 þ g 01 ego i þ a 01 network i þ g 10 x ij þ m 0i þ ε ijð3þ because the outcomes are count variables we use poisson and negative binomial regressions to answer the second question how do international ties influence research productivity poisson regression is usually used for modeling count data but when the count data exhibits overdispersion a situation in which the conditional variance is greater than the conditional mean negative binomial regression is more appropriate results we conducted analyses for faculty and students separately because of the heterogeneity of the two groups descriptive statistics table 1 shows the descriptive statistics of all the variables in our study with regard to the characteristics of egos 63 of students and 74 of faculty are male 19 of students and 77 of faculty are married and 19 of students and 80 of faculty have been abroad for graduate training students range in age from 22 to 43 with the mean being 2785 whereas faculty range in age from 29 to 68 with the mean being 4842 on average students spend 8361 of their time on research and have written 117 manuscripts in the last 12 months and the figures for faculty are 5938 and 614 the hours that students spent on research is relatively long this is due to the fact that the graduate curriculum in science in japan was modeled after the european apprenticeship style in which students rarely take classes but work on research projects alongside their advisors 32 in singapore although patterned after the us in that it comprises a course work component and a thesis research component the course work component requires the student to complete only 6 modules personal communication as such the singaporean graduate students in science spend more time on research than the us students compared to these two countries taiwans graduate curriculum in science is heavily patterned after us institutions given that most faculty and professors in taiwan have obtained their doctoral degrees in the us 33 in addition students have on average attended 248 conference with 099 being international conferences and published 077 papers in total with 021 papers in top journals from 2007 to 2010 the figures for faculty are 1110 conferences 517 international conferences 1171 papers in total and 392 papers published in top journals in terms of the characteristics of alters and ties 70 of students alters and 77 of facultys are male on average students have known each alter for 340 years and spend 18142 minutes in discussion with each alter for faculty the figures are 923 years and 12659 minutes some 6 of students ties and 17 of facultys are international for students 34 of communications are via conversation alone 3 via nonconversation modes and 63 involve both conversation and nonconversation for faculty the figures are 12 8 and 80 respectively finally for students 33 of egos and alters are a mentormentee relationship 45 peers 4 partners and 18 others for faculty the figures are 22 55 3 and 20 as for the characteristics of whole networks network size averages 49 for students and 50 for faculty males account for 70 of students total networks and 79 of facultys international ties represent 5 of students total network ties and 19 for faculty only 3 of communications in students total networks and 9 in those of facultys are limited to nonconversational channels mentormentee relationships account for 37 of students ties and 18 of facultys on average students have known alters in their total networks for 361 years and spend 18832 minutes on discussion with these alters the figures for faculty are 963 years and 12982 minutes formation of international ties next we used multilevel logistic models to examine how international ties are associated with characteristics of egos alters ties and networks model 1 in table 2 considers only the effects of ego characteristics on the formation of international ties controlling for country for students marital status and experience in graduate training abroad are significantly associated with international ties students who are married are less likely to form international ties than students who are not married students who have been abroad for graduate training are more likely to form international ties than students who have not for faculty no ego characteristics are significantly associated with the formation of international ties in model 2 the characteristics of alters and ties are added for students one alter characteristic and three tie characteristics are significantly associated with the formation of international ties first the length of time for which a student has known an alter is positively associated with a tie being international the longer a student has known an alter the more likely it is that the tie is international second the intensity of discussion is negatively associated with a tie being international the longer the discussion the lower odds that the tie is international this makes sense because the egos and international alters are less likely to be close to each other in terms of both time and geographic distance third the mode of communication is associated with international ties using 1 conversational mode and 2 both conversational and nonconversational mode is negatively associated with a tie being international compared with strictly nonconversational mode communication that is if the student uses only nonconversational mode to communicate with an alter it is more likely that this tie is international this finding is expected because of the potential difficulties in communicating via conversational mode due to time differences and geographic distance finally the relationship of the tie is also associated with a tie being international compared with a peer relationship a relationship related to partner is more likely to be international for faculty the three tie characteristics aforementioned are also significantly associated with the formation of international ties first similarly the longer the discussion is the lower the odds that the tie is international second likewise if faculty use only a nonconversational mode to communicate with alters it is more likely that this tie is international third compared with a peer relationship a relationship related to mentormentee is less likely to be international whereas a relationship related to partner is more likely to be international it is worth noting that after adding the characteristics of alters and ties in model 2 one ego characteristicegos genderwhich is not significant in model 1 becomes significant male faculty are less likely to form international ties than female faculty model 3 adds the characteristics of networks for students no network characteristics are significantly associated with crossnational ties for faculty four network characteristics have significant effects first the proportion of men in ones network is positively associated with a crossnational tie faculty who have a higher proportion of men in their networks are more likely to form international ties second the proportion of mentormentee relationships in ones network is negatively associated with international ties faculty who have a higher proportion of mentormentee relationships in their network are less likely to form international ties third the mean length of time for which faculty have known the alters in their network is negatively associated with the formation of international ties the longer mean length of time for which the faculty have known network members the lower the odds that these ties are international last the mean intensity of discussion between faculty and alters is positively associated with the formation of international ties the longer the mean length of discussion the higher odds that these ties are international international ties and research productivity finally we turned to poisson and negative binomial regressions to examine whether and how international ties influence research productivity after controlling for egolevel characteristics other network characteristics and country as shown in table 3 manuscripts and papers in top journals among students are analyzed using poisson regressions all the others are analyzed using negative binomial regressions due to the overdispersion of the count data we will first present results of the students and then results of the faculty for students the proportion of international ties in ones network is significantly and positively associated with the number of manuscripts and the total number of published papers but is not significantly associated with the number of papers published in top journals students who have a higher proportion of international ties in their networks wrote more manuscripts and published more papers in total but the proportion of international ties made no difference in terms of publishing papers in top journals in addition to the proportion of international ties in ones network other network characteristics are also significantly associated with research productivity first the proportion of men in ones network is positively associated with only the total number of papers published students who have a higher proportion of men in their network tend to publish more papers second the proportion of mentormentee relationships is only positively associated with the number of papers published in top journals students who have a higher proportion of mentormentee relationships tend to publish more papers in top journals third the mean length of time for which students have known alters in their total network is positively associated with the number of manuscripts but negatively associated with the number of published papers the longer time for which students knew their network members the more manuscripts they wrote but the fewer papers they published characteristics of ego influence students research productivity as well the number of conferences attended students age and marital status are significantly associated with research productivity students who attended more conferences tended to be more productive in terms of all three indicators second married students tended to publish both more papers in total and in top journals third the linear and quadratic terms of age are significant for the number of papers published in total and in top journals suggesting a curvilinear relationship between age and the number of papers published in total and in top journals as students age increased for faculty the proportion of international ties in ones network is significantly and positively associated with only the number of papers published in top journals faculty who have a higher proportion of international ties in their network published more papers in top journals as for other network characteristics the proportion of men in ones network is positively associated with all three indicators of productivity faculty who have a higher proportion of men in their network tend to be more productive although previous studies 3435 identified no gender difference for collaboration among industrialorganizational psychologists and in economics it is possible that male scientists are more connected than women scientiststhe so called old boy networkin life sciences finally the mean length of time for which faculty have known alters in their total network is negatively associated with the number of manuscripts and the total number of papers published the longer mean length of time for which faculty knew their network members the fewer manuscripts they wrote and fewer papers they published we speculate that this may be related to studies regarding strong and weak ties 203637 studies show that weak ties are more important than strong ties to generate new ideas 36 which implies that strong ties may not be as beneficial as weak ties regarding a facultys productivity this finding is also consistent with a study by petersen 20 which found that collaborators frequently change over time in science based on coauthorship analysis in terms of the egos characteristics similarly the linear and quadratic terms of age are significant for 1 the number of manuscripts and 2 the number of papers published in top journals suggesting a curvilinear relationship between age and the two outcomes in addition faculty who attended more conferences tended to publish more papers in total discussion students our findings suggest that overseas graduate training can be a key factor for a graduate students ability to form international ties in these three countries living and studying abroad provides opportunities for students to build their professional networks with international scholars this will likely lead to future collaboration jonkers and tijssens 38 examined the relationship between research productivity and overseas experience among a sample of leading chinese plant molecular life scientists who returned to their home country after receiving research experience abroad their results also supported that in general overseas research training experience has a positive impact on publication productivity they attributed the benefit of the overseas experience to increasing skills and knowledge as well as connecting to professional networks internationally a faculty member in singapore expressed the benefit of studying in the united states i think the us has a lot to offer for sure the breadth of knowledge and the networks that the us has built up are truly amazing i think the working attitude especially at the university this drive for excellence and real impact is amazing in the u s sm02 a graduate student from singapore realized the importance of graduate training overseas and wished for more opportunities i think there should be more exchange program for graduate students i think you get to learn more about your research field and see how other universities how they work and also you have a better network of collaboration in future if you want ss07 governmental organizations appeared to understand the importance of studying overseas for example the china scholarship council in china provides funds for graduate students and postdocs to study overseas some faculty believed that not only skills and knowledge but also diverse approaches to identifying scientific problems were gained through studying abroad a taiwanese faculty mentioned somehow when i was in the united states i feel much much more flexibility the um the school system and the professor the professor give me more much much more um room much much more time for me to pursue my own goal but uh my experience here uh the faculty members they have their own topics or subjects and usually like the students to follow the topic or subject tm17 moreover the network that they developed in host countries can benefit their research even after they returned to their home countries in the data set we examined for example we found that students who have a higher proportion of international ties in their networks tend to write more manuscripts and publish more papers even after controlling for overseas graduate training while graduate training itself has no effect on writing more manuscripts and publishing more papers this suggests that research productivity based on these two indicators can be attributed to the social capital that students developed from the time they spent in their host countries rather than the skills and knowledge that they developed when studying abroad or the possibility that students who had overseas graduate training were simply better students in these three countries however we also found that international ties have no effect on publishing papers in top journals whereas graduate training abroad is positively associated with publishing papers in top journals in this study this seems to suggest that when it comes to research productivity based on quality rather than quantity the social capital that students obtained abroad does not matter instead what matters is the skills and knowledge that they obtained abroad or the quality of students themselves a comment by a taiwanese faculty member testified to this latter assertion usually in taiwan good students only get a master degree and then they go to usa to get their phd degrees just like me i get a masters degree in taiwan and then i go to usa to get phd degree in fact this faculty member lamented the situation because it is very difficult to keep excellent students in taiwan to collaborate with although he further mentioned i think they have their right to do their choice and sometimes if they go to usa they go to a good laboratory and they find a good supervisor i am happy for them too other faculty members believed that studying overseas is important to becoming good scientists so i usually just tell my students you need toif you have a chanceyou need to go abroad to study everybody can buy facilities money hardware but the the strategy and attitude and those things you cannot learn in a short term you need to go to the overseas tm30 unfortunately there is no way to test formally our speculations about the issue of causality and selectionthe notion that students become more productive because they receive training abroad versus the notion that good students who are potentially more productive are more likely to go abroadother than these interview data because we did not collect data on this question this line of research could be pursued in future studies faculty as for faculty we found patterns that are distinctive from students facultys international ties have no effect on writing more manuscripts or publishing more papers but do have an effect on publishing more papers in top journals in this study this suggests that reaching out to international researchers can benefit scientists research productivity in terms of quality rather than quantity in these three countries guerrero bote et als study 25 also found that papers with international collaborators tend to have higher citations conducting high quality research may require better equipment overseas or different expertise available only in foreign countries because the countries studied have relatively small research communities they may have to reach beyond their borders to obtain the resources needed the different patterns between students and faculty may reflect faculty and students differences in the use of international ties or that there is less variance in ability and motivation among faculty than among students of course the international relationships that scientists cultivate may vary as ynalvez and shrum 32 found in their study of professional networks among scientists in the philippines those scientists who had graduate degrees from japan tended to have strong longlasting relationships compared to those who studied in the us and australia they speculated that this may be due to the curriculum differencemore apprenticeship in japanand mentoring style differencemore personal frequent and close mentoring we also found that graduate training abroad has no effect on research productivity for faculty this is probably because the majority of faculty in these three countries have overseas graduate training the faculty in taiwan tended to be taiwanese scientists who obtained their phds from foreign institutions primarily the us uk japan or australia and came back to take positions at universities in taiwan in contrast the faculty in singapore are not necessarily from singapore where universities actively recruit foreign academics 39 as such all faculty we interviewed except for three obtained their doctorate from foreign countries such as canada germany the us and india all faculty in japan except for one obtained their phds from japanese institutions these findings also have practical implications pouring resources into sending science graduate students to overseas universities will likely generate a high return on investment because these students tend to form international ties and as a result they are more likely to publish more papers and write more manuscripts thus these countries should feel encouraged to support exchange programs with overseas universities as well as to provide funds for students to study abroad however sending students overseas is not the only way to foster international ties instead of sending students overseas a university in taiwan initiated a program to invite scholars from other countries to come to taiwan a faculty member explained how it works this time we will invite scholar from the us another time we will invite scholar from japan too so when they come these two faculty need to sit together to discuss the service of the courses and when they have decided the syllabus goes to our faculty community to approve it and after that the course will be offered to the student and the student can choose this as a course as they want to enroll in i think its not only benefit students but also benefits the faculties because they can come here for a long time like two or three weeks we ask them the invited scholars to in addition to the teaching course maybe stay in the lab to interact with the faculty and the lab members tm30 personal communication this is an innovative way to foster crossnational ties he further mentioned how inviting foreign scholars could lead to future collaboration the student and faculty also benefit a lot and also they can set up the future cooperation because they know each other they will say oh this the field we are working on the same field so they can even the week they stay they can discuss the future research project tools tm30 personal communication limitations and conclusion as with any study the findings here should be interpreted with discretion first the sample size for the study is relatively small due to resource constraints we were only able to collect data from approximately 100 scientists in each of the three countries as such the generalization of the studys findings is limited although the findings may be applicable to countries with similar conditions second we conducted surveys and interviews at the same time if we had administered the surveys and followed up with interviews to ask specific questions regarding the results of the survey analysis the study could have been richer nevertheless the combination of both quantitative network surveys and qualitative interviews did provide different types of data and insights opposed to some previous studies that solely focused on either coauthorship data or social network analysis 18 19 20 22 third this studys results were primarily derived from empirical data not from a set of hypotheses based on a theoretical concept as is typical in social science studies although the study was rather explanatory in nature we addressed a void in the literature and identified further research directions in conclusion this study examined both graduate students and faculty in three east asian countries in regard to their international ties and research productivity the data indicate that graduate students in our sample who have received graduate training overseas are more likely to have crossnational ties in their egocentric social network which has positive impacts on their productivity although many other factors influence a students productivity interview data also indicate a series of benefits that students gain from studying overseas although graduate training overseas was not a factor for productivity among faculty faculty with international ties are more likely to publish in top journals thus fostering international ties for countries like japan singapore and taiwan is considered important and governments should support such efforts through funding and policies this study addressed faculty and graduate students professional networks using egocentric social network analysis the networks that we examined were identified via interviews by asking with whom individuals discuss their research these networks are not officially recorded elsewhere because these relationships may not appear in explicit coauthorship networks however as other studies have mentioned it is useful to identify support networks for researchers as a type of scientific collaboration 211 this study sheds light on the relationships between these networks for productivity s2 file questionnaire for students the questionnaire was used to collect data from doctoral students the minimal data sets in csv format is available through indiana universitys data repository called iu scholarworks the url of the data is handlenet202221710 supporting information s1 file questionnaire for faculty the questionnaire was used to collect data from faculty data curation marcus antonius ynalvez formal analysis noriko hara hui chen

prior studies showed that scientists professional networks contribute to research productivity but little work has examined what factors predict the formation of professional networks this study sought to 1 examine what factors predict the formation of international ties between faculty and graduate students and 2 identify how these international ties would affect publication productivity in three east asian countries facetoface surveys and indepth semistructured interviews were conducted with a sample of faculty and doctoral students in life sciences at 10 research institutions in japan singapore and taiwan our final sample consisted of 290 respondents 84 faculty and 206 doctoral students and 1435 network members we used egocentric social network analysis to examine the structure of international ties and how they relate to research productivity our findings suggest that overseas graduate training can be a key factor in graduate students development of international ties in these countries those with a higher proportion of international ties in their professional networks were likely to have published more papers and written more manuscripts for faculty international ties did not affect the number of manuscripts written or of papers published but did correlate with an increase in publishing in top journals the networks we examined were identified by asking study participants with whom they discuss their research because the relationships may not appear in explicit coauthorship networks these networks were not officially recorded elsewhere this study sheds light on the relationships of these invisible support networks to researcher productivity

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introduction globally people who inject drugs constitute 510 of individuals living with hiv 1 idu face an heightened risk of hiv infection largely due to shared drug paraphernalia including syringes and crack pipes 23 in canada an estimated 134 of those living with hiv are idu 2 although earlier diagnosis of hiv through testing has been shown to improve health outcomes and survival of patients 4 idu often present to healthcare only after aidsrelated opportunistic infections have developed 3 further benefits of routine hiv voluntary counselling and testing include reduced risk behaviours conducive to hiv transmission and increased uptake of antiretroviral therapy following diagnosis 56 many barriers to vct among idu have been identified distrust of the healthcare system and primary care providers are leading concerns 78 peerdelivered vct represents a unique opportunity to circumvent these barriers in various studies health services delivered by nonmedical providers were shown to lower financial costs and result in equal or improved quality of care and service uptake particularly among hardtoreach populations 8 9 10 11 12 13 certain organizations in vancouvers downtown eastside neighbourhood such as the supervised injection facility insite and the community organization vancouver area network of drug users incorporate peerdelivery into their programming 14 however little is known about the acceptability of peerdelivered vct among the idu population as no such programs currently exist therefore this research sought to characterize idus willingness to receive peerdelivered vct in vancouver canada methods data for this research were drawn from the vancouver injection drug users study a prospective cohort of hivnegative idu recruited through street outreach and selfreferral since 1996 the study has been described in detail previously 15 participants complete baseline and semiannual followup questionnaires that elicit a range of information including demographic data information on drug use and hiv risk behaviours and experiences with healthcare blood samples are also collected for serologic testing the vidus study has been approved by the university of british columbiaprovidence healthcare research ethics board this study employs crosssectional data from participants who completed a survey between december 2011 and may 2012 seven observations with missing data were excluded from analysis during this followup period only new survey questions asked respondents who they would want to administer hiv pretest counselling rapid hiv test and hiv posttest results and counselling for each question possible responses included doctor nurse outreachcommunity worker peer from insite someone from vandu close friend acquaintance someone with street experience social worker hiv support worker hiv specialist anyone or other participants selected all that applied thus categories were not mutually exclusive participants were considered willing to receive peerdelivered services if they selected at least one of an insite or vandu peer a close friend acquaintance someone with street experience or anyone as these categories are generally comprised of current or former members of the idu community the three distinct outcomes explored by this study are willingness to receive peerdelivered pretest counselling peerdelivered rapid hiv testing and peerdelivered posttest counselling pearsons chisquared tests were conducted for bivariate analysis except where 5 or fewer individuals existed in one or more cells in this instance fischers exact test was used odds ratios were calculated using simple logistic regression analyses three multivariate regression models were then constructed using the akaike information criterion and pvalues each of the three models were initially constructed to include all variables where p 005 in bivariate analyses then reduced by progressively removing the variable with the greatest pvalue until no variables remained for inclusion the model with the lowest aic score was selected for reporting all pvalues were twosided results in total 600 participants were included in this study seven observations were excluded from analysis due to missing data 195 respondents were female 301 were aged ≥48 years 375 selfidentified as caucasian and 153 selfidentified as aboriginal 143 respondents were current members of vandu 450 had used insite in the past and 136 reported smoking crack cocaine daily overall 309 individuals indicated willingness to receive peerdelivered pretest counselling 244 to receive peerdelivered rapid hiv testing and 257 indicated willingness to receive peerdelivered posttest counselling in bivariate analyses reported in table 1 the following characteristics were significantly associated with willingness to receive peerdelivered pretest counselling drug dealing 171 95 confidence interval 110265 daily crack smoking daily heroin injection injecting with others always or usually having used insite and being a current member of vandu factors significantly associated with willingness to receive peerdelivered rapid hiv testing included drug dealing daily crack smoking daily heroin injection having used insite and being a current member of vandu factors significantly associated with willingness to receive peerdelivered hiv test results and posttest counselling were daily crack smoking daily heroin injection injecting with others always or usually having used insite and being a current member of vandu as shown in table 2 multivariate analyses identified the following factors to be significantly associated with willingness to receive peerbased pretest counselling having used insite 185 95 ci 125272 and being a current member of vandu daily crack smoking and having used insite were significantly associated with willingness to receive peerdelivered rapid hiv testing willingness to receive peerdelivered posttest counselling was significantly associated with male gender frequent crack smoking having used insite and being a current member of vandu discussion our study found moderately high levels of willingness to receive peerdelivered hiv vct among idu in vancouver canada willingness was predicted by previous exposure to peerdelivered programming and markers of higher intensity drug use specifically frequent crack smoking these findings may reflect the potential for peerbased services to overcome various barriers to vct associated with traditional vct delivery specifically peerdelivered vct may help address issues such as lack of trust in the healthcare system physicians unfamiliarity with the social conditions surrounding idu and discomfort awaiting test results 78 we found that more idu were willing to receive peerdelivered pretest counselling than testing and posttest counselling a previous study from thailand found similar results which were later explained by concerns about confidentiality and peers ability to correctly administer tests 16 idu in our sample who had used insite vancouvers supervised injection facility which involves peer workers or were members of the peerrun organization vandu were more willing to engage in peerdelivered vct these results complement findings from a study in thailand which found that idu who had engaged with a peerrun dropin centre also expressed high willingness to receive peerdelivered vct 17 given the potential importance of peerdelivery in the provision of hivrelated services there may be value in implementing peerdelivered vct within already established peerrun organizations to increase access to vct within the community high willingness for peerdelivered vct among frequent crack cocaine users may be explained by previous research which found that perceived risk exposure constituted a main reason to seek hiv testing 7 due to ongoing educational efforts in vancouvers downtown eastside it is likely that idu acknowledge crack cocaine use as a risk factor for hiv infection vancouver coastal health authoritys crack pipe distribution program which occurred between 2011 and 2012 represents one example of such efforts 18 in vancouver in 2011 a vct pilot project delivered hiv counselling and testing to idu through peers in conjunction with nurses an evaluation of the program found positive results but no largescale peerdelivered vct was implemented 19 research in melbourne australia also investigated a program of peerdelivered hepatitis c counselling and testing among idu and found improvement in risk behaviours and knowledge of hepatitis c 20 the findings from the present study are consistent with these studies and provide evidence that idu are willing to engage in peerdelivered vct these types of programs and services should therefore be brought to scale our study has limitations first our sample was built using snowball sampling methods and was not randomly selected therefore residual confounding may exist and results may not be generalizable second we relied on selfreporting which may subject our results to response bias lastly our analysis is crosssectional in nature and could be extended by future longitudinal and intervention research assessing how reported willingness compares to actual willingness to receive peerdelivered vct overall this study highlights the potential of supplementing traditional vct strategies with peerdelivered approaches tailored to idu what is already known on this subject peerbased approaches have been successful in delivering hivrelated interventions this type of taskshifting from primary healthcare providers has been shown to increase quality of care and reduce costs of service delivery what this study adds this study provides evidence that people who inject drugs support the use of peerdelivered hiv voluntary counselling and testing associations between involvement with community services or peerbased networks indicate that these organizations may be key rollout points for peerbased vct services results also suggest that idu who know they are participating in highrisk activities may be more likely to take advantage of lowbarrier vct opportunities

backgroundpeople who inject drugs idu face unique systemic social and individual barriers to conventional hiv voluntary counselling and testing vct programs peerdelivered approaches represent a possible alternative to improve rates of testing among this population methodscrosssectional data from a prospective cohort of idu in vancouver canada were collected between december 2011 and may 2012 bivariate statistics and multivariate logistic regression were used to identify the prevalence of and factors associated with willingness to receive peerdelivered vct resultsof 600 individuals 515 indicated willingness to receive peerdelivered pretest counselling 407 to receive peerdelivered rapid hiv testing and 428 to receive peerdelivered posttest counselling multivariate analyses found significant positive associations between willingness for pretest counselling and having used vancouvers supervised injection facility insite or being a member of vandu a local drug user organization all p 005 daily crack smoking and having used insite were positively associated with willingness to receive peerdelivered hiv testing p 005 willingness to receive peerdelivered posttest counselling was positively associated with male gender daily crack smoking having used insite and being a member of vandu p 005 while not universally acceptable peerdelivered vct approaches may improve access to hiv testing among idu

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introduction maternal depression is a highly prevalent condition with serious consequences for children approximately 10 of american mothers experience depression each year and children of depressed women are more likely to experience psychopathology than other youth however the association between maternal depression and childrens physical health is less clear 3 two studies have suggested that children of depressed women are more likely to exhibit poor health based on maternal ratings research exploring the impact of maternal depression on offspring weight has been mixed and studies exploring the influence of maternal depression on behavioral practices that affect childrens wellbeing such as breastfeeding has also produced equivocal results however several studies have concluded that depressed women are less likely to utilize recommended infant sleep practices beyond infancy evidence indicates that depressed women are less likely to have rules about childrens food consumption and families with depressed mothers are less likely to eat dinner together to date the most extensive research supporting an association between maternal depression and offspring health relates to healthcare utilization children of depressed women are more likely to be hospitalized and use acute care services than other children youth with a history of maternal depression are also less likely to receive preventative services such as vaccinations and healthcare expenditures for children are significantly higher among families with parental depression together these findings suggest that while there is some evidence for the deleterious effects of maternal depression on offspring physical health additional research is needed to fully understand this relationship including the impact of poor childhood health on maternal depression the contribution of environmental variables to both maternal depression and poor child health and the mechanisms through which maternal depression might impact offspring health maternal engagement with children is a promising potential mechanism given established associations between depression and diminished engagement among mothers including reduced likelihood of playing with or reading to children and less verbal interaction with infants studies have demonstrated that parenting behaviors and maternal engagement partially mediate the association between maternal depression and youth psychopathology although little is known about how decreased engagement among depressed mothers impacts physical health the single existing study on the topic found that reduced parenting quality mediated the associated between maternal depression and higher childhood body mass index of note the influence of maternal depression on childrens health is particularly relevant among lowincome families lowincome mothers are at increased risk for depression and depressed women are more likely to experience changes in economic status that can affect health including reduced welfare support and loss of food stamp benefits additionally maternal depression may be one pathway through which poverty influences childrens wellbeing including obesity food insecurity psychopathology and cognitive development and the association between maternal depression and reduced engagement is strongest among lowincome women thus studies that clarify the specific effects of maternal depression on children in lowincome families are greatly needed the present study seeks to address notable gaps in the literature by examining the influence of maternal depression on offspring physical health including health status health behaviors and healthcare utilization in a lowincome sample additional analyses explore maternal engagement as a mediator we hypothesized that maternal depressive symptoms would be associated with poorer offspring physical health less healthy nutrition behaviors reduced utilization of appropriate healthcare services and lower maternal engagement additionally we predicted that reduced engagement would mediate the association between maternal depressive symptoms and poor offspring physical health methods statistical analyses in the initial set of analyses maternal depression status was dichotomized and used to predict metrics of offspring physical health due to variability in the frequency with which various responses were endorsed categorical outcome variables were dichotomized and examined using logistic regression most analyses predicting count outcomes utilized poisson regression however the variable representing average daily sugary drinks was overdispersed so zeroinflated negative binomial regression was employed results are presented in the form of odds ratios and incidence rate ratios and include 95 confidence intervals additional analyses assessed maternal engagement as a mediator of obtained direct effects these analyses utilized a composite variable created by summing the five maternal engagement items conditional process analyses were conducted using the process macro for spss which employs bootstrapping to estimate direct and indirect effects biascorrected 95 cis determined the statistical significance of obtained effects indirect effects in which the 95 ci did not include zero supported maternal engagement as a mediator all analyses included several covariates preferred language maternal education maternal employment maternal health insurance coverage family income vs 501100 of fpl vs 100 of fpl child gender whether the childs father was actively involved in his or her life maternal age and child age results descriptive statistics most women identified as hispanic while the remainder identified as africanamerican caucasian asian or pacific islander or other women in the present sample ranged in age from 15 to 51 years with an average age of 3051 children ranged in age from less than 1 year to 50 years with an average age of 242 most women had graduated from high school 1 3 and a majority were not currently working most women and children had health insurance most women reported that their family income fell at or below 100 of the fpl the 2014 fpl for a family of four was 23550 table 1 displays the demographic characteristics of the sample by maternal depression status statistically significant differences between depressed and nondepressed women were observed for all variables other than child gender with depressed women demonstrating the most marked differences in preferred language of the interview education and health insurance status table 2 provides descriptive statistics for outcome variables by maternal depression status highlighting several significant group differences including the likelihood of receiving medical care in a public setting maternal depressive symptoms and offspring physical health analyses predicting offspring physical health indicated that preschoolage children of depressed women were 234 times more likely to be rated by their mothers as having poor or fair health than children of nondepressed women children of depressed women also ate vegetables at a reduced daily rate vegetables compared to other children and demonstrated 118 times the daily rate of eating sweets such as cookies candy and sweetened cereal additionally children of depressed women exhibited 133 times the daily rate of consuming sugary drinks such as soda chocolate milk or gatorade and were 121 times more likely to eat fast food at least once per week healthcare utilization also varied by maternal depressive symptoms children of depressed women were 166 times more likely to be uninsured and were maternal engagement as a mediator maternal engagement mediated several of the observed associations between maternal depression and offspring physical health including average daily vegetable consumption average daily sugary drink consumption and average daily sweets consumption maternal engagement also mediated the association between maternal depression and child health insurance coverage and the likelihood of receiving medical care from a public source in all instances maternal depression was associated with reduced engagement which was linked to negative health outcomes discussion the present study sought to clarify the impact of maternal depressive symptoms on offspring physical health among lowincome families consistent with hypotheses preschoolage children of depressed women exhibited poorer motherrated general health less healthy eating habits and reduced likelihood of having health insurance or receiving care from a private doctor compared to offspring of nondepressed women children of depressed women were also less likely to be read to told stories or taught letters words and numbers at home furthermore lower maternal engagement mediated the link between maternal depression and 1 3 several outcomes including reduced vegetable consumption increased consumption of sugary drinks and sweets and increased likelihood of being uninsured or receiving medical care from a public source of note all effects were observed after controlling for maternal education employment status preferred language age and health insurance coverage in addition to family income child age child gender and involvement of the childs father in his or her life findings suggest that offspring physical health and maternal engagement are linked to maternal depression and indicate that diminished engagement may be one pathway through which depressed women negatively affect their childrens physical health the relationship between maternal depressive symptoms and offspring physical health is complex and bidirectional the present results suggest that depressed women are more likely to rate their preschoolage children as being in poor health and exhibiting unhealthy eating behaviors which may be due to characteristics of both the child and the mother this association is also affected by accesschildren of depressed women in the present study were less likely to have health insurance and more likely to receive medical services in a community or hospital clinic which may be related to motivational features of depressed women and environmental factors that simultaneously reduce healthcare access and decrease mood the present results suggest that intervening at the level of the mother child or environment would help to improve outcomes among lowincome families and failing to intervene may condemn lowincome children to a lifetime of poor health and other negative consequences including reduced educational and wealth attainment independent of maternal depression children from lowincome families exhibit markedly poorer physical and mental health into adulthood and specific behaviors that were found to be associated with maternal depression in the present study such as unhealthy eating habits can have negative longterm consequences including increased risk of cardiovascular disease thus maternal depression may disadvantage lowincome children even further additionally the transactional nature of these variables over time may contribute to adverse outcomes for the family as a whole including reinforcing cycles of poverty and poor health across generations furthermore the results suggest that depressed women are less likely to engage in enrichment activities with their children and that reduced maternal engagement might partially explain the link between maternal depression and several negative health outcomes these findings corroborate a prior study that found parental quality mediated the association between maternal depression and child bmi in addition to research highlighting the role of engagement as a mechanism of maternal depressions effect on offspring psychopathology the present results are the strengths of the present study include the use of a large highly diverse community sample and the ability to examine the effects of maternal depression on offspring over and above the influence of relevant demographic characteristics the sample included a relatively high proportion of women who endorsed at least one depressive symptom allowing for greater understanding of the link between maternal depression and offspring health the focus on lowincome women and children a population particularly vulnerable to poor physical and mental health is also a major strength the use of crosssectional selfreport data is an important study limitation causal relationships cannot be ascertained and negative cognitive biases associated with depression may have influenced womens report of their childs health therefore the findings likely overestimate the association between maternal depression and offspring health additionally crosssectional data cannot definitely rule out a causal association opposite to that tested in which poor child health leads to increases in maternal depression the present study was unable to assess chronic health conditions among children that may have contributed to maternal depressive symptoms and could not rule out other variables that may negatively impact both maternal mental health and offspring physical wellbeing furthermore mediation cannot be definitively established within crosssectional datasets future studies should employ longitudinal designs to establish clear temporal associations between maternal depression offspring physical health and possible mediators given the surveys broad focus a more comprehensive depression scale could not be included maternal depressive symptoms were measured using two items and women were coded as depressed if they endorsed at least one item on several days or more in the last 2 weeks therefore the threshold above which women were characterized as experiencing depressive symptoms was quite low and the psychometric properties of this measure among lowincome women are unknown however given the low threshold required to meet criteria for depressive symptoms in the present study the negative health outcomes among children of depressed women are notable and suggest that mothers with clinicallysignificant levels of depression may be even more likely to contribute to poor child health than is represented here while maternal depressive symptoms only accounted for a small proportion of the relative risk of negative offspring health outcomes in the present study the results suggest that reducing depressive symptoms among lowincome women could have implications beyond the health of the women themselves increased implementation of interventions designed to prevent and treat depression among lowincome women could improve current and longterm physical and mental health among children in addition to reducing poverty across the lifespan both medication and psychotherapy have been identified as effective interventions among depressed lowincome women and studies have found that administering brief screening measures to pregnant women in obstetric care settings can accurately identify women at risk for depression unfortunately many individuals suffering from maternal depression have never received treatment highlighting the need for broader screening increased prevention efforts among atrisk women and greater access to affordable treatments partnerships between wic sites and managed care providers could provide a venue for lowincome women to access mental health treatment while taking positive steps toward their childrens health the present results suggest that providing depressed women with effective lowcost treatment is a public health issue with implications beyond the immediate wellbeing of the mother interventions targeting maternal depression may also improve child physical health nutrition and healthcare utilization longitudinal studies aimed at clarifying the temporal and causal relationships among maternal depression and offspring physical health must be conducted to inform policy that will enhance quality of life among lowincome women and their children funding the funding was provided by national science foundation first 5 la

objectives the present study sought to examine the association between maternal depressive symptoms and characteristics of offspring physical health including health status health behaviors and healthcare utilization among lowincome families maternal engagement was explored as a mediator of observed effects methods crosssectional survey data from a community sample of 4589 lowincome women and their preschoolage children participating in the wic program in los angeles county were analyzed using logistic poisson and zeroinflated negative binomial regression mediation was tested via conditional process analyses results after controlling for the effects of demographic characteristics including maternal health insurance coverage employment status education and preferred language children of depressed women n 1025 were significantly more likely than children of nondepressed women n 3564 to receive a poor or fair maternal rating of general health or 234 eat fewer vegetables irr 094 more sweets irr 120 and sugary drinks daily irr 132 and consume fast food more often or 121 these children were also less likely to have health insurance or 159 and more likely to receive medical care from a public medical clinic or hospital emergency room or 130 reduced maternal engagement partially mediated associations between maternal depressive symptoms and several child health outcomes including poor diet health insurance coverage and use of public medical services conclusions for practice maternal depressive symptoms are associated with poor health among preschoolage children in lowincome families prevention screening and treatment efforts aimed at reducing the prevalence of maternal depression may positively affect young childrens healthalthough maternal depression is associated with poor mental health among offspring its impact on childrens physical health is not wellestablished particularly among lowincome families for whom the risk of parental depression is heightened findings support associations between maternal depression and metrics of offspring physical health including poorer nutrition and decreased likelihood of insurance coverage and provide preliminary evidence that maternal engagement may mediate this relationship results highlight the broad influence of maternal mental health on family wellbeing and suggest that identifying women at risk for depression implementing prevention efforts and increasing treatment access will benefit childrens mental and physical health

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background south asians are the second fastest growing racialethnic group in the united states after latinos 1 south asians have an elevated risk of cardiovascular disease and diabetes mellitus and a higher ischemic heart disease mortality rate than nonlatino whites and other asians 2 3 4 5 6 despite a growing body of research to explain and reduce these disparities individual health behavior and clinical risk factors do not fully explain south asians elevated cardiometabolic risk 37 further individual level prevention interventions have had limited success in this high risk group thus widening inquiry beyond the individual to the larger social drivers of health 11 may offer key insights into the lesswell documented social context of health outcomes in atrisk communities prior research suggests that social relationships exert an especially important influence on behaviors and beliefs of south asians in the us 12 13 14 15 almost 90 of us south asians are first generation immigrants who believe that kinship and family ties are paramount with an emphasis on collectivism social control and maintenance of group identity 12 13 14 15 studies show that south asians have low levels of physical activity and dietary patterns that contribute to increased cardiometabolic risk 31617 these behaviors are socially and culturally informed 1819 yet there is limited understanding of the structure composition and function of social network ties among south asians the cultural patterning of networks and how social relationships influence the health of this community understanding south asians social lives their specific functions and how they are linked to health can help inform effective interpersonal and communitylevel health interventions for the rapidly growing south asian community social networks influence health via many mechanisms including social influence and control establishment of health beliefs and normative behaviors feelings of shared identity and belonging access to resources and provision of support 2021 social networks transmit information attitudes and behaviors that determine health outcomes 20 early understandings of network processes suggested mechanisms of network influence through social diffusion such that new ideas and behaviors are spread through contact with other people who have already adopted the behavior 22 in addition voluntary affiliation and participation in a community religious or social organization has also been shown to influence network composition social support and health 23 voluntary membership in organizations has the potential to create more or less diverse social connections and exposure to additional sources of social influence norms and support thus measurement of both personal social networks and organizational affiliation may provide novel insights into the social influence processes relevant to health in south asians the overall goal of this research project was to investigate both personal social networks and organizational affiliation in south asian community religious or social organizations among individuals who participated in the mediators of atherosclerosis in south asians living in america study a prospective communitybased cohort study on cvd risk and incidence in the us south asian population 24 although a body of research has shown that social networks are associated with health behaviors and outcomes there is almost nothing known about the personal social networks and organizational affiliations of south asian immigrants in the us 2526 this study provides the unique opportunity to advance research on the cultural patterning of social connections in south asian immigrants and begins to explore the linkages between social networks and health methods ethics consent and permissions the study protocol and procedures were approved by two institutional review boards and all study participants signed informed consent measurement of personal social networks from 20142017 the masala study participants were reenrolled for a 2 nd study visit where personal network characteristics were measured using a standard egocentric approach that examined the network members reported by the respondent the surveys were administered in english hindi or urdu by trained interviewers to collect egocentric network data on respondents close confidantes interviewers asked respondents to enumerate relevant alters by using a name generator that has been used by the the general social survey 27 and the national social life health and aging projects social networks module 28 to collect data on participants core confidants interviewers asked participants to list the people with whom they discuss important matters respondents could name up to ten people this name generator was selected to identify network confidants who have opportunities to exert social influence and normative pressure 2029 studies using this approach have yielded important insights about social contacts who are particularly influential 30 31 32 following the enumeration of alters the interviewers continued with name interpreter questions which were used to collect information about the first five network members who were listed limiting responses to five individuals is a typical approach to reduce respondent burden and the first alters names typically represent the most important individuals within the social network name interpreters helped to characterise the type of relationships sociodemographic characteristics strength of relationship functions of the network members discussion topics and frequency of communication among the five alters measurement of organizational affiliation south asians in the us have developed organizational structures that may exert a strong influence on social connections social support and cultural beliefs related to health behaviors we developed a roster of south asian organizations in chicago and the san francisco bay area using key informant input and an iterative approach respondents were asked to look through the predefined list and circle the organization that they visited within the prior 12 months and to also circle how frequently they visited the organization in the prior 12 months respondents could choose multiple organizations if applicable and they were also given the option to add an organization if it was not on the roster there was no limit on the number of organizations a person could affiliate with however after reporting all their organizational ties respondents were only asked in more detail about the 6 places they attended most frequently the study team limited additional responses to the 6 organizations visited most frequently to reduce participant burden and because the organizations visited most frequently were likely to have the greatest influence after data collection the organizations were coded as communitybased organizations spiritual organizations and places of worship we used the internal revenue service definition for coding these and distinguishing spiritual organizations from places of organized worship spiritual organizations focused on religious and spiritual teaching but were nondenominational not considered places of worship and did not provide organized religious services like a church temple or mosque social network measures the masala network data are provided in a dyadlevel file in which each row contains information about a specific network member for a given respondent the most basic measure of personal network structure was size the number of names mentioned in response to the first name generator question the remaining network variables were calculated using information on the first five individuals listed in response to the name generator question density was defined as the number of ties divided by the number of pairs 33 a tie was defined as whether or not there was any reported communication between two alters a fully dense network indicates that all network members were connected to each other densely connected networks typically have a great deal of influence on an individuals behavior but may not offer access to new information or resources whereas sparsely connected networks may allow for the introduction of new information but may provide less tangible support 34 network composition variables which examine characteristics of alters included the proportion of specific characteristics south asian origin household member kin and gender in a masala respondents network we also calculated the average closeness rating to 5 across alters and the volume of contact with alters as contactdaysyear based on the participants reports of how often they talked to each alter on a 5point scale ranging from every day to a few times a year we calculated the average number of organizational affiliations for each participant assessing social support the interview asked respondents about emotional social support and instrumental social support received from the five alters responses were categorized as most of the time sometimes and rarelynever we also asked respondents to report on negative social interactions with each alter such as how often does alter name make too many emotional or physical demands on you and how often does alter name criticize you health outcomes selfrated health was measured by asking participants to rate their health on a continuous scale of 110 with 1 being poor health and 10 being excellent health a categorical measure of selfrated health was avoided given there is a wide range of variability in how those of ethnic minority status and foreign born perceive these categories of health 35 for each alter listed the interviewer asked suppose you had a health problem that you were concerned about or needed to make an important decision about your own medical treatment how likely is it that you would talk with name about this would you say very likely somewhat likely or not likely this question was the same as what was used in nshap we calculated the proportion of the network that the participant was very likely to talk with about health respondent sociodemographics and cultural characteristics information on participants education income age marital status birthplace number of years living in the us and religion were collected as previously described 24 cultural characteristics were captured using multiple items the traditional beliefs scale was a continuous measure asking participants how much they wished south asian cultural traditions would be practiced in the us examples of these cultural traditions centered upon food related activities and partaking in arranged marriage practices 36 the scale had a cronbachs alpha coefficient of 81 and ranged from 0 to 28 with lower scores reflecting stronger cultural beliefs and higher scores reflecting weaker cultural beliefs we also asked participants about cultural selfidentity by asking them to report on a scale of 110 how south asian do you feel and how american do you feel statistical analysis we calculated descriptive statistics for all variables of interest including participant characteristics network characteristics alter relationships alter characteristics and organizational ties we examined bivariate associations between participant and network characteristics using pearsons correlations and tested whether these correlations were significantly different from 0 network variables were modeled as continous variables for presentation in tables we categorized some continuous participant characteristics because it allowed us to clearly describe how network characteristics may differ as a function of participant characteristics however when calculating correlations participant characteristics were analyzed on their original scale in order to better preserve relationships between participant characteristics and network characteristics and also to avoid the loss of statistical power that would be the result of collapsing continuous data into discrete categories we described alter social support and negative social interactions by their relationship to the ego we also described participants organizational affiliation by organization type and attendance at healthrelated events at these organizations lastly we used adjusted linear regression models to examine if network density closeness with alters network composition variables and number of organization affiliations were associated with selfrated health or the proportion of the network with which the ego was very likely to discuss hisher health each network characteristic was included as a predictor in separate regression models adjusted for age sex education and network size all statistical tests were performed using twosided tests with α 005 and were conducted using sas version 94 results participant characteristics the masala study participants who completed the social network module were on average 59 years old 43 were women and 90 were married or with a partner overall participants had high income levels and high education with 88 having at least a bachelors degree the majority of masala participants were born outside the us and 65 had been living in the us for more than 25 years participants mean selfrated health was 79 and ranged from 3 to 10 network size and composition among the 700 participants there were a total of 2932 network members identified all participants reported at least one confidant and the average network size was 6 over two thirds of the sample reported that they had at least five or more confidants the correlation between network variables is shown in additional file 1 table s1 overall south asians personal networks were mostly comprised of kin and the majority of network members were south asian there were however some significant differences by sociodemographic characteristics and cultural identity compared to the youngest age group older south asians had social networks that were significantly more kincentered and more south asian older south asians were also affiliated with more south asian organizations than those in the youngest age group education and income were also associated with different social network compositions individuals in the highest education and income categories had significantly larger networks that had a lower proportion of kin compared to those with less education cultural beliefs and identity were also significantly associated with network composition individuals with stronger traditional south asian cultural beliefs had more ethnically homogenous networks than south asians with weaker traditional beliefs a stronger south asian identity was positively and significantly associated with network kin proportion proportion south asian and the number of affiliations with south asian organizations emotional closeness and volume of contact south asians reported being emotionally very close to their confidants and on average respondents reported three contacts per day with a close confidant egos said they mostly communicated with over half of their network inperson and with 41 by telephone women married individuals and respondents with a stronger south asian identity reported significantly more contact with their network members as age increased south asians had a significantly lower volume of contact per year with network members network density network density is a measure of all possible ties that existed between alters overall south asians had high density networks with 78 of all possible ties among alters being present older individuals less educated respondents and those who were marriedliving with a partner had significantly more dense networks social support and negative social interactions participants reported lower levels of emotional support than instrumental support from their network members south asians said they could talk about their worries most of the time with 54 of all network members with spousespartners being the most common source of emotional support participants said they could rely on 94 of spousespartners 80 of children and twothirds of siblings friends or other kin most of the time if they had a problem and needed help negative social interactions were more common with spousespartners and children than other types of alters across all networks 52 of spousespartners and 33 of children were described as making too many emotional physical or psychological demands sometimesmost of the time and 61 and 38 respectively were described as criticizing the ego organizational ties the 700 participants in this study reported a total of 3213 organizational ties the majority of organizational ties were with places of worship among the 2411 organizations that participants visited most frequently over 51 of these ties were long standing and participants reported feeling close to 67 of the organizations attendance at these organizations was perceived as beneficial to health ranging from 68 of community based organizations to 88 of mosques being perceived as beneficial participants reported talking with other people at 80 of organizations they attended but few attended any healthrelated events at these places association of social network characteristics with health outcomes in unadjusted and adjusted linear regression models only closeness to alters was significantly associated with selfrated health as closeness with alters increased selfrated health increased several network characteristics were associated with the proportion of the network that the ego was very likely to discuss hishealth with overall the proportion of network members that participants were very likely to discuss a health problem with was 065 network density and closeness to alters were each positively associated with the network proportion involved in health discussions a higher proportion of kin and a higher proportion of south asians were also significantly associated with a higher proportion of the network involved in health discussions the proportion of women in the network volume of contact with alters and number of organizational affiliations were not associated with health discussions discussion the masala social networks ancillary study is the first comprehesive profile of middleand olderaged south asian adults social networks and association of network characteristics and functions with health we found that south asians living in the us have a relatively large confidant network which is mainly kincentered and comprised of individuals who are also south asian network characteristics including size composition and density varied by participants age sex education income and cultural factors suggesting potentially important subgroup differences in social context which in turn effects sources of influence and support as well as types of information and resources available to south asian immigrants we also found that networks that were more dense emotionally closer and had a higher proportion of kin and south asians were positively associated with healthrelated discussions until now there have been no data on social networks and health in us south asians and less than a handful of studies on south asians in india and the united kingdom we found that south asians reported larger confidant networks compared to prior studies in the us and india however previous network studies may not have captured the full extent of the personal network because they placed a smaller limit on the number of alters reported during the name generator the present study used a more openended approach and allowed respondents to name up to 10 people during the name generator our study may be more reflective of true network size 262837 similar to latino immigrants in the us 37 south asian immigrants appeared to have dense kincentered networks that were ethnically homogenous eighty percent of network ties among urban asian indians were family members 26 although this is slightly higher than what we found both studies demonstrate that family relationships are central to south asian social networks interestingly in our study several social and cultural factors were associated with the proportion kin higher education and income and a stronger american identity and weaker south asian identity were associated with a significantly lower proportion of kin in the network suggesting that socioeconomic status and cultural change influence social network composition others have also shown that lower socioeconomic status is associated with a higher proportion of kin in us populations 3338 we also examined different types social support and interactions among south asians and found that family members were most common sources of emotional and instrumental support interestingly south asians appeared to report less emotional support from network members including family than instrumental however the questions used in our survey may not have distingushed between the availability of support and seeking support this may be an important distinction since some crosscultural studies have indicated that asian americans tend to seek less support than other racialethnic groups 39 our findings deserve further exploration to determine if there are differences in willingness of south asians to share emotional concerns and seek emotional support compared to other types of social support future analyses will examine if there are links between network characteristics types of social support and health in south asians the findings that weaker south asian ethnic identity and weaker traditional cultural beliefs were associated with networks that were less ethnically homogenous and less dense may have important implications for the norms health information and resources available to south asians others have found that ethnocultural identity impacted peer group choices and was associated with personal network composition in immigrant adolescents 4041 as a next step we will examine if these network differences are associated with differences in social norms influence and support among south asians immigrants which in turn could influence health and behavior we also found that south asian immigrants associate with and attend a large number of local south asian organizations including community social and religious institututions participants perceived attendance at these organizations as beneficial to their health and reported socializing with other members suggesting that south asian organizations may provide additional sources of support and social connections in addition coparticipation in south asian organizations also provides the opportunity for exisiting norms and behaviors to be reinforced as a next step we will examine if attendance and affiliation with these organizations influences health behaviors and outcomes 29 and if coparticipation by masala study participants in specific organizations is associated with diet exercise and obesity 42 our findings are a starting point for determining if south asian community structures can be leveraged for health interventions religious and spiritual organizations were the most commonly reported affiliations and the potential of these organizations for health promotion and intervention should be explored others have found associations between social networks and selfrated health 4344 with smaller networks being associated with worse health in the elderly and larger more familybased networks being associated with better selfreported health in our study we only found that greater emotional closeness with alters associated with better selfrated health 21 but did not find associations with network size or proportion kin close alters may provide higher levels of social support or access to other resources that improve perceived health we also showed that network structure and composition including density closeness and proportion kin were associated with health discussions among south asians and their network members our data lend additional empiric support to prior studies showing that south asian immigrants rely on close family members for health information and advice 45 how these health discussions influence behaviors or health outcomes is an area that has yet to be explored it would also be intersting to investigate if specific health issues are as likely to be discussed in south asian families as general health problems although an egocentric study provides a feasible way of obtaining network information on a largescale it has several limitations egocentric data is based purely upon the knowledge reflection and recall of the ego which may be inaccurateespecially when describing the relationship between two alters 46 because we did not observe alters view of relationships we were not able to validate the ego selfreport the analysis is still relevant however if we consider the fact that an egos perception of relationships may be more important than whether or not the perceived relationship is validated by the alter 47 we also did not ask participants about affiliations with nonsouth asian organizations or about organizations outside their state of residence thus limiting our understanding of the full range of potential organizational associations south asians may have however the organizations in the roster represent the major organizations in the lives of south asians in addition because of the crosssectional study design causality cannot be inferred lastly the masala study cohort includes middleand olderaged south asians the majority of whom are asian indian immigrants with high socieconomic status importantly our response rate to the social networks module was 78 and nonresponders were more likely to have low socieconomic status and be women while the sociodemographics of the masala cohort are similar to that of the general us asian indian population 48 these results may not be generalizable to all south asians in particular the social networks of usborn south asians may be quite different from those who immigrated as adults conclusions peoples social lives shape their beliefs norms and availability of social support all of which influence behavior and health this is the first study to describe the structure and composition of us south asians personal social networks and organizational affiliation and provides new insight into the patterning of social relationships in this growing community the masala networks data will be used to examine how participants attributes network members characteristics organizational membership and the nature of their relationships with each other contribute to diet exercise weight and cardiovascular health outcomes this study provides a unique opportunity to investigate the connections between health and social context and to inform networkbased health interventions to improve the health and wellbeing of us south asians additional file additional file 1 table s1 competing interests the authors declare that they have no competing interests

background understanding the social lives of south asian immigrants in the united states us and their influence on health can inform interpersonal and communitylevel health interventions for this growing community this paper describe the rationale survey design measurement and network properties of 700 south asian individuals in the mediators of atherosclerosis in south asians living in america masala social networks ancillary study methods masala is a communitybased cohort established in 2010 to understand risk factors for cardiovascular disease among south asians living in the us survey data collection on personal social networks occurred between 2014 and 2017 network measurements included size composition density and organizational affiliations data on participants selfrated health and social support functions and healthrelated discussions among network members were also collected results participants age ranged from 44 to 84 average 59 years and 57 were men south asians had large size56 sd26 kincentered proportion kin071 sd028 and dense networks affiliation with religious and spiritual organizations was perceived as beneficial to health emotional closeness with network members was positively associated with participants selfrated health pvalue 0001 and networks with higher density and more kin were significantly associated with healthrelated discussions discussion the masala networks study advances research on the cultural patterning of social relationships and sources of social support in south asians living in the us future analyses will examine how personal social networks and organizational affiliations influence south asians health behaviors and outcomes

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introduction 1 do tradeshows have a distinct role in creating nascent markets and in the later constitution of distinct industries other than general references to the historical development of markets from trade fairs in preindustrial societies the existing literature provides no theoretical model of the emergence of a cluster of interrelated markets from trade shows this study fills the existing void in the literature by examining the role of a traveling tradeshow in the us microelectronics sector during the second half of the 1990s in creating the market for real time computing products these products which emerged from various military technologies support many of the internet applications we use today such as video on demand and various online computer games this paper which uses ethnographic research methods also describes the emergence of a labour market in and around the traveling trade show there is a large body of research that addresses the general question of how economic actors cope with distinct forms of uncertainty but more importantly the uncertainty of the products this paper shows that attempts to organize a trade show in real time computing were triggered by two types of uncertainties which we claim are unique to markets for emergent technology the uncertainty experienced by some sellers regarding the identity and qualities of prospective buyers and an uncertainty about the desired use or application of the innovative products produced by small engineering firms in a craftlike production mode the traveling show we studied was designed by its founder to reduce these uncertainties the concentration of buyers and sellers in a specific geographic location occasioned in turn the emergence of forms of collaboration competition common identity and importantly the constitution of subsidiary markets such as a distinct labour market for technically qualified salespeople of real time computing products the identification and ordering of market actors the institutionalization of a distinct business culture and the social networks developed among market actors and across the subsidiary markets provided the social infrastructure for what later became known as the real time computing industry this study also makes a contribution in stressing the importance of tracing the history of emerging economic fields a topic that seems to have attracted little serious study we claim that trade shows for innovative products as well as other market devices are venues in which the various components of an industry come together this paper expands the existing literature on trade shows and fairs by demonstrating historically how trade shows constitute several embedded markets which with time comprise an industry we demonstrate that trade shows may also be vital for the perpetuation of markets and industries over time and space 2 there are three interrelated concepts that we use in this paper trade show market and industry a market is a social structure for the exchange of rights in which offers are evaluated and priced and compete with one another which is shorthand for the fact that actors individuals and firmscompete with one another via offers competition as a form of struggle is implicit in our view of market and it may refer to competition among sellers or buyers or both though the term market is probably the most frequently used our interest is in the other two since markets are well researched in economic sociology we define the term trade show as an event which appears with regularity yet for a limited time on each occasion the tradeshow is typically set up in the form of an exhibition centered on what sellers have to offer this means that one side of the market typically the sellers has artifacts on display which can be seen by the buyers in this paper we define industry as more than a group of products that share some technical characteristics the term industry includes the set of actors oriented towards the production and sale in markets revolving around a specific artifact or a set of artifacts which are seen by market actors as similar or related the output of an industry is tied to one single core market and what is sold is what gives the name to the industry such as the car industry in addition to the core market and its sellers and buyers an industry is composed of auxiliary service and labour markets all of which are embedded in each other each industry as its markets is characterized by distinct cultural traits which include forms of competition and cooperation among insiders both firms and persons accepted scripts of social behavior and distinct ways of closing a transaction the culture of a distinct industry provides an actor with clear behavioral scripts which allow her to be seen by other market actors as a legitimate player as we intend to demonstrate the traveling trade show studied was the location where the different components of market and later industry start to take shape next we review existing literature on trade shows and industries previous research on fairs trade shows and nascent industries the modern tradeshow has its origins in the county fair the latter represents an archaic form and place of exchange where different items changed hands within the broader context of a carnival such fairs also included artistic performances gambling drinking and prostitution the feast may be seen as a forerunner to the fair the county fair was one type of an early market which took place at certain dates and places and which for these reasons can be called a periodic market fairs were held at least as far back as the 11 th century in europe in many cases fairs were traveling markets which included a large element of festivity and a break from the normal toil of life braudel describes the ancient fairs as temporary townships they did not last for long but the very number of their participants was equal to that of a town from time to time they would set up all their equipment then when everything was over move away the fair then reappeared according to a wellknown schedule for tradesmen the fairs meant the opportunity to come together to trade with each other and to establish social relations and a basic sense of trust in some cases the towns controlled the tradefairs but in other cases it was the other way around in fact the fairs once its tradesmen settled down could be the impetus for the constitution of a city alfred marshall stresses the importance of exchanging information at the fairs of the 14 th century the great fairs were like modern exhibitions schools in which people learned that the habits and resources of their own villages and even their own countries represented but a small part of what went on in the world in the 15 th century fairs enabled the development of credit in the form of bills of exchange more importantly fairs enabled people to come together and the networks of traders that resulted from meeting in various places were important for the expansion in diversity and volume of trade over in the 16 th century marshall sees fairs as events at which items that were made in only one or two places in europe were brought together it is not unlikely that the trust created by trade at fairs was then employed in the nascent financial sector and this trust may have sparked the emergence of banks a similar idea is voiced by weber who characterizes fairs as trade in which the goods are present the fair he says is a prior stage of the exchange and the permanent fair is an intermediate form of exchange leading to the exchange that we can observe also in contemporary stock exchanges the peak of the fairs in western europe was in the 17 th century when they were a major engine of the emerging capitalist economy fairs gradually lost in importance because of the rise of the permanent trading places and financial centers most notably amsterdam given this brief historical overview it is surprising that in the information age and with so many permanent trading places trade fairs still exist we will return to this question in our discussion the research on contemporary tradeshows is relatively limited yet this does not reflect a decrease in their role in economic exchange today trade shows have moved into large and often secluded exhibition halls and they thereby have become hidden from the eyes of the public including sociologists while clearly more specialized in nature trade shows continue to provide a physical location where industries coalesce skov has studied trade shows in the fashion industry her study of different shows for couture ready to wear and textiles each catering to a specific market illustrates how the fashion industry is composed of several markets embedded in each other a market implies competition which is to say that the evaluation of the offers is facilitated by spatial proximity and the modularity of exhibitions units creates the conditions for a direct comparison of different companies against the backdrop of similarity entwistle and rocamora have also analyzed the fashion industry focusing on the london fashion week they argue that this trade show makes the industry its boundaries and its actors visible to themselves and to others the spatial distribution of exhibitors in a tradeshow is not the only means to create a market for example colored badges carried by the participants in the fair create a collective identity but also social distinctions between the market actors as a way of making it easy for those who attend to match their interests awards for the best design of garment a chair or any other items exhibited are typical of trade showstrade shows are also an integral part of the labour market in these industries the shows are of value for both recruiting firms and for individuals looking for new positions in addition there is also a socializing aspect of catching up with old friends all this takes place inside but also outside the actual halls of the show for example in bars restaurants and on the dance floor some of the studies mentioned above illustrate and explain the ordering of industries through status displays and the status order of the exhibitors at the show cognitively actors must share a common perception of what the industry is maintain a physical proximity and agree upon forms of collaboration between insiders these elements create a sense of solidarity among the market actors which is central for the creation of a market the culture of the industry essentially the normative structure and the behavioral scripts which characterize specific industries also takes shape in part during trade shows thus tradeshows were arenas for generating trust the foundation on which all contracts rest they also had the potential to stimulate urban development as well as markets and industries hence the studies which we reviewed so far inform us that a trade show is much more than a display of items for sale it is a place of knowledge distribution and a location where buyers and sellers strive to reduce the array of uncertainties they encounter and to foster a basic sense of trust trade shows are also a site for industrial espionage and a place of networking by establishing and upholding contacts with business partners as well as with potential clients trade shows provide a symbolic stage for market actors ie firms and individuals to demonstrate economic might to both the other exhibitors and the visitors as an audience the public demonstration of technology is also an important aspect of marketing the explanations which we offer about the role of tradeshows in shaping embedded markets and then an emerging industry start with a description of two specific forms of uncertainty which plagued the nascent market for real time computing in the mid 1990s uncertainty regarding the identity of prospective buyers and uncertainty regarding the nature of the products and their uses the uncertainty experienced by both buyers and sellers in turn shapes patterns of social relations among the sellers collaboration as well as competition and ties among sellers and buyers we will demonstrate how the pattern of interaction among market actors orders the industry and reduces the uncertainty experienced by sellers and buyers in addition to the questions of uncertainty and the emergence of market and industry we also aim to expand existing knowledge by posing the following questions what role does the physical space of the trade show play for market actors and for the formation of a market what role do social activities during the show play to what extent are competition and collaboration present at trade shows if and how are values inscribed into the trade shows formal processes what is the function of the trade show for the labour market of an industry before we address these questions we present our research field the field of real time computing the real time computing sector is part of a larger field called digital signal processing real time computing products are involved in the transfer storage and processing of digital signals as they occur products in this industry often become part of larger technological systems such as test equipment videoondemand and computer games initially applications in this field were developed for and often by the us military or other government agencies for example electronic detection and surveillance of enemy radar is based on real time computing technology since the late 1980s and increasingly during the 1990s the number of small engineering boutiques producing civilian applications based on real time computing technology has grown rapidly these more recent applications allow computer networks and computerized production to proliferate many of the internet applications we use regularly are based on real time computing technology by the mid 1990s much of the trade of cuttingedge products in real time computing was conducted at a specific traveling tradeshow nicknamed by its participants the traveling circus which was held more than 40 times a year at different cities across the us in the late 1990s the show became global and also took place periodically in major western european cities the story of the show told below is also the story of the making of a market and consequently an industry for real time computing products research setting design and methods we were fortunate to study this industry from its initial stages and to witness its growth along the years we can also demonstrate that trade shows in this industry still have an important role today the ethnographic depiction of a traveling trade show is part of a larger comparative study of sales work in a market for emergent technology conducted by darr the study was carried out in the us during the second half of the 1990s the data for the comparative study were collected over the period of one year as part of the study 62 representatives of buyers and sellers including sales engineers field application engineers salespeople purchasing agents and design and test engineers were interviewed the interviews lasted about an hour each and were taperecorded fiftyfour interviews were transcribed in full and eight were transcribed in part in addition darr documented interactions between sellers and buyers at six trade shows two of which were in a mass market for standard electronics products and four in the real time computing market at the displays he observed and documented in field notes over 100 interactions between sellers and buyers in the two markets he also surveyed salespeople in the traveling trade show the questions focused on the careers and educational background of the sellers at the show finally short conversations with visitors to the show were conducted on site to learn about the occupational background and the types of uncertainty encountered by the buyers overcoming client and product uncertainty the study of the interrelation of market uncertainty and economic action has been a point of convergence for economists of information economic sociologists and anthropologists a look at this literature suggests that different cultures tend to develop distinct forms of economic action to reduce their uncertainty regarding product quality business partners and cost geertz for example describes the practice of clientalization in the moroccan bazaar as the tendency of buyers to establish social relationships with certain sellers and to repeatedly buy from them as a coping strategy in conditions of high product uncertainty gambetta portrays how the local mafioso becomes a middle man for a commission in a horse market in the late 19 th century the mafioso assists sellers and buyers to reduce their market uncertainty by providing assurances backed by the threat of violence about the quality of the horse as well as the buyers timely payments to the seller in contemporary usa and europe smith depicts public auction as an uncertainty reduction mechanism designed to establish a products value within a community of experts in a specific place and time aspers has studied the status as a way of ordering markets lucien karpik has analyzed the role of what he calls judgment devices that is social inventions that help actors in markets to form opinion on the quality of the traded object as we will demonstrate the types of uncertainty in the emerging market for real time products go far beyond product quality and cost and focus on more basic issues such as the identification and ordering of a body of sellers and buyers and the uncertainty regarding the basic features design and capabilities of the emergent technology being sold actors who take part in the early phase of market constitution need to know who is in the market what role they and others occupy and what is traded the traveling circus the first and main tradeshow in the real time computing sector was established by an owner of a small hightech firm who as he described in a telephone interview wanted to ascertain his potential clients as there was no public arena at the time to identify and socialize with them as a group the first show he organized was very successful since apparently he was not the only producer who suffered from what we will call client uncertainty the founder soon abandoned his small engineering firm in favor of running the trade show and he hired a specialized workforce to assist him within a few years the show was held all over the usa and became a periodic fair information about how to participate in the tradeshow was circulated in two main ways advertisements for the traveling show were placed in specialized journals of real time computing second information travelled by word of mouth from vendors who participated in the show to other vendors in the field who met at other shows within the field of digital signal processing the idea behind the traveling trade show was to bring cuttingedge technologies in the emerging real time computing sector to the doorstep of prospective clients who mainly consist of design and test engineers working for very large corporations and government agencies such as nasa general electric and xerox clients were typically very large corporations since they had to sponsor a vast labourintensive and costly customization process of the original products on sale to adapt them to their specific needsthus the person who initiated the show created a periodic marketplace and thereby provided a central element which gradually became a set of interrelated markets which provide the infrastructure for an industry this initial organization of the markets was indeed an entrepreneurial action trade shows were acknowledged by sales test and design engineers and firm managers who participated in them as an efficient way to overcome client uncertainty as one experienced sales engineer in the real time computing industry explained referring to his startup company one thing we have learned from participating in trade shows is to understand who our potential customers might be he said that they did not know this before they attended the show and then added on the basis of the shows we have attended we had a tremendous amount of travel lately we have learned what they the clients need how the dell people differentiate themselves from ibm for although they all offer pcs they see themselves in different ways the informant makes two important and related points first for him the trade show provided an opportunity for sellers and buyers to interact socially to get to know of each others but also to get to know each other second this excerpt exemplifies the range of client characteristics in which the vending companies were interested while interacting with prospective clients the vendors attempted to understand the types of products on which they worked and what subsection of their prototypes they might need from the vendor second by interacting vendors were able to map out the diversity on the buyers side but also establish their collective identity as sellers of real time computing components in this field as in any field actors made use of cultural tools to set themselves apart from rivals it is by this interaction that participants in the trade show could learn about for example the unique political landscape in clients organizations consequently it was not uncommon to hear a sales engineer asking a visiting engineer who in his company would have to approve any future purchase how the purchasing process evolved and who reported to whom in more theoretical terms the trade show facilitated a complex process of differentiation of buyers and sellers what was the experience of sellers and buyers participating in the traveling show the shows were mainly held in very large ballrooms of major hotels approximately 40 companies displayed their products on simpleand identical tables covered with a standard white piece of cloth for about 500 a vendor could participate in two shows held in two adjacent cities within a single week there are of course many different ways such a trade show could be organized it was clear that the road taken in our case reflected the egalitarian values of the founder values that are shared by others in this young industry for example from its initial days as explained by the founder the show was designed to favor the interests of small firms operating in the real time computing market and not already established and larger companies trying to penetrate and possibly take control of the emerging market no company regardless of the amount of money it was ready to pay to the show organizers could display its products on more than one table typically a traveling tradeshow in real time computing was held in the downtown area of a large city near potential clients such as xerox corporation in upstate new york or texas instruments in houston texas the show organizers issued formal invitations to each show and the vendors were responsible for sending these invitations to their existing or potential clients the majority of the visitors were engineers but mediators between firms and potential clients were also invited the practice of sending private and personal invitations insured the creation of a collective social capital within the emerging market it also encouraged the creation of a specialized body of buyers that increased the chance for successful encounters compared to more general tradeshows which admitted whoever was ready to pay for admission the show was carefully designed to encourage the local engineers working for these large corporations who received the invitations to visit the show mainly during their lunch breaks and to walk around the display tables organized in two or three long isles admission to the show and parking were free the most important fringe benefit that was offered to the visitors was a free lunch market actors in industries include not only buyers and sellers but also mediators of exchange for example at one of the shows a sharplydressed man who thereby stood out from the other attendees walked around talking briefly with some of the vendors it turned out that he worked for a local office which represented manufacturers in the field of electronics in the city where the show was held and that he was looking for companies his office would be interested in representing as he put it conversations i have here with vendors give me a chance to establish a common ground and make a little better relationship this person like many of the sellers and the buyers was also an engineer by education thus the trade show was also the location where mediators operated and established their social networks of representation suggesting that it is an important site for the creation of the social foundations of a market as durkheim has already pointed out the traveling show propelled the creation of the real time computing market in yet another way it made the existence of an emerging market public by providing a physical location as well as a symbolic stage which appeared with some regularity for example the show allowed the various actors to know who was in the market and to assign specific roles to them in addition the show allowed the actors to learn about the type range and technical complexity of the products offered for sale and thus to get a better sense of the boundaries of the emerging market and the potential applications of its products to the actors it was a recurrent event manifested in spacesexhibition halls that helped to create a sense of collective identity and shared understanding of belonging since the same people come together again and again to constitute the roles of sellers and buyerswe turn now to describe how the trade show assisted in reducing client and product uncertainty the visitors to the trade show mostly young male engineers found out while walking through the display tables that they were unfamiliar with many of the products on display and with the vendors who were representing small engineering firms from different parts of the usa here is an example given by a seller in the trade show reflecting the way he understood the experience of the visitors or buyers at the show what you are going to see at trade shows is people who are exposed to something for the first time in other words they go to the show looking for something and they are going to come to a booth with something they are going to think is what they want and they want to be pulled in by the vendors and they are going to be shown the product the innovative products on display were typically produced by small engineering boutiques in a process resembling craft production during the preindustrial era more than mass production in fact one might claim that the visitors uncertainty was typical of the feeling of a visitor to a local market in preindustrial societies such as the moroccan bazaar described by geertz this form of uncertainty is not uncommon in the starting phase of market or industries in fact when there is no way to determine what is valued in the market one can hardly speak of a market or industry at all in other words there is no order in the emerging market as long as it is unclear what is offered for sale there are in principle two ways of establishing order in a market the first is to make sure that the product is standardized so that all actors can orient themselves to this product in our case the innovative products were hardly standardized since their exact use was still unclear the other way is for buyers to have a stable social structure with sellers with known identities who are ranked in relation to each other but in emerging markets and industries neither the product nor the social structure is stable enough to establish order in cases like ours the first step toward order occurs when some actors leave the traveling tradeshow as they realize that this is not what they do or need at the same time as others are attracted to it thus we cannot think of an industry constitution as a process of discursive change it is the practical interaction of humans in trade shows who are tied to organizations and who engage in daily boundary work which constitute the baseline of markets and then industry the products themselves also have an important role in shaping the structure and content of social interactions at the trade show let us look more closely at the product to clarify its role in the process of constitution of markets since the products offered for sale on the display tables represented cutting edge technologies the visiting engineers often found it hard to assess the quality of the products on display their production costs and if their going prices were reasonable in addition they suffered from uncertainty regarding the expected use of some of the products on display to use the terminology developed in technology studies the products for sale enjoyed what has been called interpretive flexibility that is different social groups buyers and sellers in our case had different interpretations of the use of these products the visitors to the show soon realized that they had to engage in intense technological conversations with the vendors standing next to their display booths in order to reduce the uncertainty created by the question what exactly is the product and how can we use it vendors in turn suffer from productrelated uncertainty they are also uncertain about their peers about exactly what they should offer and about whom their clients will be a central part of being in the market is to establish contact with the right people but it also means avoiding contacts that lead nowhere the following excerpt from a discussion with a veteran vendor at the traveling show clearly makes this pointthis vendor had experience from a less specialized and much larger show in electronics in the south of the usa and gives one example of what could happen in those less specialized shows a cowboy came up to me and listened carefully to my explanations on one of the circuit boards he then picked the board up and looked very thoroughly at the metal frame he pointed to two small pieces of metal coming out of the frame and asked me very seriously whether they were microwave antennas the informant bursts into laughter to further increase the likelihood of matching appropriate participants in the trade show a signaling device the name tag was designed to quickly and efficiently connect vendors with the most suitable buyers when visitors registered at the entrance to the show they were given a special name tag with their names and the name of their companies in clearly visible fonts while the visitors walked through the aisles and observed the display booths the vendors could approach those who they felt were potential buyers hey robert how are things at ge was a typical opening line used by the sales engineers to initiate sales interaction a further aspect of the constitution of the trade show is its culture there are many informal rules of how to do a show here is an example given by an experienced sales manager who had participated in many trade shows a lot of people do not know how to do shows shows are really there to give you the most benefit for the buck where you get exposure to a lot of people very quickly and then you follow the regular sales process it is usually critical the very beginning of the sales process it is important to note that the vendors did not expect to sell the product at the show but rather to ignite a sales process which in practice means to create a small database of what they called qualified leads basically names of firms and contact people whose applications seemed most promising in this sense the trade show was only an initial stage in a long sales process sometimes lasting several months and occasionally even more than a year while interacting with potential clients at the show the vendors initiated a series of screening questions to the buyers to determine if their product could become part of the prototype the visiting engineers were designing since most products offered for sale had to be customized according to the exact way in which the buyers needed to use them the feasibility of the customization process became a major source of uncertainty for both sides of the transaction to reduce the uncertainty for both buyers and sellers the vendors often used product demonstrations which assisted the potential buyers in inspecting the functioning of the software or hardware offered for sale and also assisted the vendors in understanding the way in which the buyers wanted to use the product the product demonstrations were also an occasion to transfer contextual elements of knowledge about the product and the clients application in search of a feasible customization process the traveling show was designed to assist the buyers and the sellers to reduce the different types of uncertainties they might encounter at the same time the show also provided a symbolic stage on which market actors could perform a diverse set of social roles a symbolic stage for an emergent market it is a simple fact that the real time computing industry could only have become an industry given the spatial concentration of interacting sellers and buyers in the trade show these interactions enabled socialization and comparison of different offers and strategies of participants this physical location was also the symbolic stage on which ingenuity and economic might were publically displayed with both visitors and other vendors acting as an audience participation at the show was in itself a symbolic indication that the company was alive and well this is after all a sector with a staggering failure rate for new businesses during the first five years of their existence failing to participate as one informant pointed out might be interpreted by other vendors as an indication that the company had run into financial difficultiesas one vendor in the show put it being in the show in such a specialized market signals that the company is alive and well not having a booth in the show might be interpreted by clients as a bad sign we previously noted the democratic ideals of the founder of the trade show another attempt to minimize the impact of large companies was evident in the methods the organizers devised to distribute the display tables according to one of the tradeshow staff in the initial stages of the show vendors simply lined up at the door the night before the opening and were admitted in that order to choose their desired table when the number of participants grew to prevent quarrels among the vendors queuing at the entrance door the organizers instituted a new system of allocating exhibition spaces the vendors were admitted to the exhibition hall according to their order of registration for the show this was still a rational and fair way of distributing value within this emerging community of equals though other shows allowed an exhibitor to pay a higher fee for a better space this strategy was not accepted in the travelling show studied socializing and networking a trade fair has its own culture and unique forms of socializing and networking as in the case of the traveling trade fairs in the late middleages food and drink were an important part of the traveling show in real time computing but in this case food was more of a strategic element rather than pure entertainment in addition to the free lunch for sellers mentioned above many of the vendors met the evening before and after the show at the hotel bar gossiping with other vendors the festive spirit of the show was also manifested in the traditional golf tournament that was partly sponsored by the organizers of the show the show organizers also established a cash prize to the company which invited the largest number of visitors who actually ended up attending the show the competition itself was a form of game and it explicitly involved the use of the prize for drinks at the bar with the other vendors after the showthis is expressed in the following example of an announcement made by the founder and organizer of the trade show at the end of one of the shows in texas close to 3 pm and after the vast majority of the visitors had already left the hotel ballroom and while some of the exhibitors were packing up their display tables show organizer allow me to interrupt you for a second my name is steve blackwell and this is our fifth year in texas and we had a good day today the number of guests today was 303 ahh and for those of you who are accustomed to the free show and the 250 cash prize we have come up with a new program that kind of spreads the wealth a bit and what we have done is the first prize winner for attracting most guests to the show is lightning systems and what we will give them is 100 plus a free show so representative of lightening systems with a hand gesture he invites them to approach him and receive the cash prize people on the show floor clap their hands now to the second prize the second prize is 75 this is for having a good time at the bar this afternoon and that goes to iron strength people around the winner say now you can invite us to the bar note that the founder presents the cash prize as a way of spreading the wealth around and thus promoting egalitarian values and a sense of community this solidarity may be central for the establishment of an industry this excerpt is also an indication of the important role of food and drink in the show harrison white suggests that market actors gain information over luncheons with others in the trade from trade associations from ones own customers and so on in other words gossip is an integral dimension of an industry to know what goes on who has closed a deal or who has a new invention up his sleeve means that you are part of the industry collaboration and competition in the early phase of their existence survival is the primary aim of firms and for those that survive profit may gradually become the dominating concern as in any market buyers in the trade show take the opportunity to compare the offers that are on display here we will not focus on competition a wellknown theme but only mention that competition may also find ways that are illegal the openness and transparency of tradefairs is important for ideas to spread collaborations to be established and much more but it also has a downside the old county fairs attracted businessmen from all walks of life not all of them motivated by virtues in a similar way the traveling trade show can serve as a site for different forms of industrial espionage for example a salesperson in the traveling show explained that after he left his previous company a person he knew who worked for one of its competitors as he put it tried to pump information out of me about the new line of products lectronix his previous firm is working on the informant claimed that he refused to provide the information in a second example a sales engineer mentioned how he was sent to the traveling show pretending to be a potential client in order to learn about the products of a competitor by simply asking many detailed questions despite competition and a few attempts at industrial espionage the tradeshow was still an important location where collaboration took place by taking part in several shows people established relations over time which are central for creating trust these relations also served as grounds for further collaborations and development of products many actors thought it better to join hands and face the uncertainty of the market and the hard pressure of rapid technological advance together with a partner firm how did they accomplish this first we should remember that all the vendors were in a similar situation the morning of the show waiting to see with great anticipation what firms might become their clients and what products they might be able to sell them in fact one vendor described the show as a lottery system and his feeling on the morning of the show as the feeling of waiting to learn if and what prize he would win at the end of the day this equal position of different vendors at the show created a basic sense of solidarity clearly expressed in this short conversation between vendors waiting at their display tables for the first visitors to arrive vendor a are you going to stick around all day bob vendor b yes vendor a well lets knock them dead this excerpt captures the excitement anxiety and hope as well as sense of a shared goal of the two vendors their similar position in the market might explain some forms of cooperation yet when asked about possible reasons for collaboration among vendors a sales engineer offered two additional reasons he said that each of the salespersons might want to seek future employment with the competitor so they wanted to maintain good relations with them by sharing information a second reason for collaboration is the high level of specialization and the lack of industry standards in real time computing at this stage in its development during the trade show the vendors learned about the products offered by other small firms in the industry and sometimes this knowledge helped in creating necessary synergy the important role of cooperation among vendors first became apparent in a regional trade show in boston and then also in the smaller traveling show in the regional show which included a greater number of firms with a much wider range of products than the traveling show and which was more international in nature one of the organizers reported in an interview that one of the most interesting features of the show is the fact that participants do lots of business among themselves in addition to the business they conduct with clients she gave an example of a show they organized in which one company did enough business with other firms participating in the show to cover all the expenses of the show a few thousand dollars because the show involved vendors of software and hardware they tended to form new alliances at the show as they were exposed to new ideas and products that could be integrated with their own this as in other forms of collaboration required vendors to study the products of the other exhibitors this they did during setup time and while waiting for potential clients for example during setup time at the traveling show in dallastexas darr walked around the displays and noticed two vendors who seemed to know each other one of them said to the other hey how are you listen you must get this stuff points to a circuit board on display in his booth tell your boss then another salesperson approached and the two of them exchanged business cards based on these examples it is clear that the traveling show is indeed a place where collaborative ties are constructed these provide means for trust to develop and mutual values and beliefs to become shared and institutionalized such collaborative ties despite their transitory nature provided the initial basis for the emerging market the constitution of a related labour market the traveling trade show is not only the location for the exchange of goods and services and the formation of collaborative ties it also provides a physical location where the vendors learn about employment opportunities gossip exchanged mainly in social gatherings at the bar or during informal meetings among vendors who tend to collaborate and who trust one another is the main means of transmitting labour market information for example a salesperson might tell a colleague that his company is seeking a new head of development or a salesperson following granovetter the importance of having many weak ties among the vendors may be the key to optimizing the recruitment or job search process it is the trade show which allows the creation of these important weak ties despite the early stage of development of the real time sector many vendors in the show knew each other from previous shows and some of them even had worked together in the same firm in their previous jobs or collaborated in the past as one of them explained yes we know a lot of people here everybody knows each other he then added in fact when kbox his previous company stopped going to the traveling shows i was very disappointed the last show i did for kbox was the dallas show last year and after that we did no more trade shows and you know it was a little disappointing because when i got back into the circus i was very glad to see everyone people i have not seen for a while and they will all go ohh where have you been you know it is funny the turnover rate in this industry people move from company to company every couple of years note that the salesperson acknowledges the social bonds which are constructed among the sellers through the shared participation and experiences at the show he also mentioned that he had changed jobs quite often but given his specialized set of skills and like many of his fellow sales people remained within the real time computing industry based on previous social interactions at the shows the information about employment opportunities is transferred between vendors whose booths are adjacent and in social gatherings in the evening before or after the show while drinking together at the bar one of the informants a vendor who regularly participated in the traveling show described his own experience and said that he got his current job while participating in the realtime show while working in a job he did not like for a company that participated in the show he approached the vice president of his current company whom he knew socially through his participation in previous shows the informant asked him about job openings it turned out he was looking for an employee and the informant was hired on the spot the emergence of a labour market around the tradeshow and the fast turnover in this nascent sector underpinned a sense of community and loyalty among the technical salespeople after all in this highly risky industry where small engineering shops struggle to survive the occupational community made up of network ties characterized by reciprocity and the appreciation of technical dexterity provided much more stable support than the employing organization this is quite common in industries where the knowledge and trust of the trade is tied to people rather than organizations trust in large organizations without direct references to specific persons within the organization is only to be expected in cases in which the firm has a proven track record over extended periods of time obviously a generalized trust in organization is not what we observe in the environment of a nascent market consequently in addition to direct economic incentives the shows foster a spirit of solidarity among the technical salespeople this spirit of solidarity facilitated collaboration and shared practice and underpinned their willingness to engage socially and to enhance their collective social capital conclusions we set out to explore the role of trade shows in the shaping of nascent markets for emergent technologies our main and most general theoretical conclusion is that the traveling show had a central role in the creation of the real time computing market first the organization of the trade show allowed market actors to reduce the two types of uncertainties that are typical of emerging markets for cutting edge technologies second while some ties were probably created directly between individual sellers and buyers in the course of designing a product the trade show allowed a group of sellers to become acquainted and to learn about the identity of a set of prospective buyers the trade show also assisted the assessment and comparison of the technical qualities capabilities and design of a defined set of products which were traded in this emerging market the collectivity of buyers and sellers could then develop shared norms and perceptions of the sociotechnical boundaries of the emerging market the trade show provided a stage on which market actors could interact the social engagement at the show created ties among participants within a short time frame while competition is an important and often implicit element of market dynamics we can see that the social encounters provided the basis for social networks based on trust and cooperation these networks in turn provide a social infrastructure for emerging markets and industries with the creation of these trustbased networks the sellers and buyers could engage in a more efficient and straightforward search for information highlighted by economists and economic sociologists about the quality and current prices of products offered for sale this study also demonstrates that the traveling show brings subsidiary markets together for example we described how a specialized labour market developed during the tradeshow and around the main market for real time computing products as sellers shared information about job opportunities often in the form of gossip which was only open to insiders thus the trade show stands at the center of a series of nested markets which taken together comprise an important pillar of what has become an emergent industry the trade show was also the location for intensive boundary work during social interactions at the show distinctions were made between those in and outside the markets through social interactions order was also gradually established as buyers sellers and mediators of exchange performed distinct roles in the market and positioned themselves and their products visàvis other market actors this initial order in turn increased predictability and facilitated calculation and planning by describing the process of establishing order in the emerging market from the early phase of orientation and by demonstrating the constitution of collaborative networks we were able to further establish that trade shows are an important venue of market creation a correlated culture of the trade show and the market including dress behavior and other scripts could gradually emerge the role of trust and business culture which started to emerge at the traveling show is connected to the physical closeness among actors that the trade show generates social capital was established at the show and the exact features and future uses of products on display were negotiated like the tradefairs in early modern europe the traveling show represent the core market brought together spatially for a concentrated period of time the tradeshow also provided a symbolic stage for small firms to exhibit technical knowhow viability and economic might by their ongoing participation in the shows we have also described the initial stages of the real time computing industry partly as an entrepreneurial act leading to the creation of a community of practitioners when buyers and sellers first met at the traveling show they began to recognize and consider each other as members of a distinct community they engaged in the evaluation of moral character as well as technical dexterity social cohesion a second stage in market creation was actively fostered by the organizer who initiated such activities as the golf tournament and the cash prize at the end of the show the latter was typically used to invite other exhibitors for a drink at the bar these activities coupled with the adoption of democratic values and the dynamic exchange of technical knowledge and knowhow among the sales engineers were institutionalized into the structure of the trade show thus promoting even further the norm of a community of equals finally the increasing digitalization of work and commerce and the proliferation of the internet have cast a shadow over the future of traditional forms of tradeshows after all the internet allows the efficient production and dissemination of information in diverse forms and sellers and buyers can share knowledge about product quality design and cost across the globe without the need for social interaction yet our study suggests that contrary to common wisdom the more archaic facetoface encounters between sellers and buyers at trade shows are actually expected to increase rather than decrease with the growing pace of technological advance in emerging fields where cutting edge technologies are traded the highly qualified sellers and buyers need to establish basic trust and a basic order by engaging in intense technological explorations carried out through an interactive facetoface engagement with their peers during the trade show the sales engineers and engineers working for prospective buyers begin to negotiate the customization process and to assess the technical and economic feasibility of specific applications the establishment of basic order and the initial constitution of collaborative networks and trust among market actors require the communication of contextual knowledge which is deeply rooted in engineering practice social engagement an interactive dialogue and the shared practice during product demonstration are the most efficient ways of communicating this contextual knowledge as long as tradeshows continue to provide a social space designed to facilitate the transfer of contextual knowledge and provide the locus of product and labour markets the traditional form of periodic yet intense facetoface encounters in a specific geographic location are likely to continue to proliferate stockholm university and university of haifa

this study addresses the question of the constitution of markets in advanced societies specifically the article studies the role of the traveling trade show in creating the real time computing market which is part of the us electronics sector during the mid1990s real time computing products assist the transfer storage and processing of digital signals in real time and support many of the internet applications we use today by applying ethnographic methods we explore the general question of how economic actors cope with uncertainty in the phase of marketmaking and at the cutting edge of technology the paper makes two contributions to the existing literature first it shows that the attempt to organize a trade show in real time computing was triggered by the uncertainty experienced by sellers regarding the identity of prospective buyers and about the exact use to which they would put the emergent technology which is offered for sale secondly we trace the history of an emergent market we claim that trade shows for innovative products are important venues at which markets coalesce the identification and ordering of market actors the institutionalization of a distinct business culture and the social networks developed among market actors and across the subsidiary markets provided the basic social infrastructure for what later became known as the real time computing industry

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background hypertension prevalence and incidence have trended upwards and are matched by epidemics of obesity and diabetes high blood pressure represents a leading global health risk and principal cause of disabilities in africa it is responsible for rising death rates from noncommunicable diseases among young and active adults 12 globally the prevalence of systolic blood pressure ≥ 140 mmhg increased from 17307 to 20526 per 100000 between 1990 and 2015 within the same period loss of disabilityadjusted life years associated with sbp ≥ 140 mmhg increased from 52 million to 78 million while the largest numbers of sbprelated deaths were caused by ischaemic heart disease haemorrhagic stroke and ischaemic stroke in 2015 about 874 million adults had sbp ≥ 140 mmhg 2 subsaharan africa is witnessing a rapid increase in urban populations correlated by the adoption of western lifestyles with a disproportionate increase in the prevalence of hypertension a common driver of the epidemic of ncds between 2000 and 2013 hypertension prevalence was estimated at 30 in ssa and ranged from 15 to 70 varying by mean ages 30 years 40 years 50 years and 60 years 3 in cameroon the prevalence of hypertension was 246 in 2006 witnessing an almost twofold increase in 2012 3 urban areas had an agestandardised prevalence of 297 and awareness of 141 4 with a rural prevalence of 311 and 29 awareness in 2013 5 studies on hypertension in ssa hardly focussed on the fulanipeul who are a diverse minority group 6 spread in 20 countries in a wide swath of west central and east africa with an estimated population of 7 to 8 million nomadic fulani and 16 million settled fulani the fulani are transitioning from traditional to transitory and modern lifestyles their access to healthcare is limited by barriers of language location and culture 7 as a result they disproportionately experience poorer health than most mainstream ethnic groups studies in cameroon highlight the existence of the hypertension pandemic and consider the population as ethnically homogenous though the incidence prevalence and risk factors of the disease vary by ethnicity 8 the current data of hypertension exhibit gender variations which are agedependent 9 extant health data on fulani populations is paltry and little is known about the occurrence distribution and drivers of hypertension amongst fulani populations though we have indicated that transition from a nomadic pastoral life to a settled life may be accompanied by an increase in the prevalence of risk factors of ncds 10 studies from different populations reported association of different anthropometric indicators with hypertension waist circumference is associated with morbidity and mortality body mass index mostly used in clinical settings is a simple and convenient though poor measure of body fat distribution 1112 in order to develop culturally embedded interventions amongst the fulani indigenous populations aimed at addressing ncds in general and cardiovascular diseases in particular we examined the epidemiology of hypertension in fulanipeul populations with a focus on age and gender variations using central obesity proxy of wc and bmi methods study population this study obtained data from a crosssectional survey in five localities inhabited for the most part by fulani in east and adamawa regions of cameroon from january to february of 2013 prior to the study a census was conducted a total of 1337 fulani or peul aged ≥ 20 years from 555 households were recorded with complete data and included in this analysis the details of the population are in our previous paper 10 sampling design a multistage cluster sampling method was used with the five sites constituting the strata 10 procedure details of data collection with structured questionnaires are described elsewhere 10 the questionnaire also assessed alcohol intake tobacco consumption salt and sugar intake fruit and vegetable consumption and sleep participants were asked whether they have ever drank alcohol and if yes the number of standard bottles or any locally produced alcoholic drink and whether they drank daily participants were asked whether they have ever smoked any tobacco products like cigarettes cigars pipes and handrolled cigarettes and if yes whether on a daily basis also whether they used to smoke in the past how many years they stopped smoking and whether they used snuff or chewing tobacco to assess their level of salt and sugar consumption participants were asked to respond by yes or no to whether they frequently added salt or sugar to food or teacoffee even when other household members thought the salt or sugar was okay fruit and vegetable intake was assessed by requesting the number of days participants consumed these food items per week data on sleep was collected by requesting participants to state whether they were satisfied with the sleep they had or had sleep disturbances and not satisfied with the sleep quality in the past 4 weeks blood pressure was measured thrice by standard methods after a participant had been seated for 5 minutes by use of fully automated calibrated omron m3 machine at 5 minutes interval the mean blood pressure value from the two highest values was used classification of measures bmi was classified according to who criteria genderspecific central obesity was defined and classified according to who guidelines and wc was used as a surrogate for central obesity 1112 hypertension defined as sbp ≥ 140 mmhg andor dbp ≥ 90 mmhg or current use of antihypertensive medication blood pressure category was defined by the highest level of blood pressure whether systolic or diastolic and categorised according to the european society of hypertension and european society of cardiology optimal systolic blood pressure was 120 mmhg and diastolic blood pressure 80 mmhg normal high normal grade 1 hypertension grade 2 hypertension grade 3 isolated systolic hypertension and diastolic isolated systolic hypertension was further graded as 1 2 or 3 13 proportion of hypertensive participants who reported having been previously diagnosed by a health professional was considered to be aware of hypertension and participants on treatment was based on those who reported taking antihypertensive medication within the past 2 weeks physical activity was classified as low moderate and vigorous depending on the intensity duration and frequency of physical activity in occupational and leisure times from the global physical activity instrument included in the questionnaire 1415 classification of alcohol consumption was into abstainers and occasional four or more of standard bottles in a single day in the past 12 months or daily drinkers of standard bottles we considered different forms of tobacco consumed and classified participants as abstainers current and daily smokers 16 fruit and vegetable intake was based on the frequency of intake per week from zero to two times a week intake was classified as low three to five times a week as moderate and six to seven times a week was considered as high 17 data management and statistical analysis data was captured with epi data 30 and analysed using stata 131 se data was weighted adjusted and computed within 95 confidence intervals and at significance of p 005 the mean for all continuous variables was computed we took into consideration the complex sampling design by use of survey commands in the analysis study participants sociodemographic and lifestyle risk factors were presented descriptively using chisquared and students t test to characterise outcome variable and covariates we examined the relationship between hypertension and covariates by univariate logistic regression in order to determine drivers of hypertension we carried out multivariable logistic analysis in a model with all significant factors in the univariate analysis adjusted for site and gender and further examined genderspecific drivers in two multivariable logistic regressions adjusted for site factors were retained by backward selection model assumptions were checked and variables were checked for collinearity and correlation ethical approval ethical approval was obtained from the national ethics committee of cameroon signed or thumbprinted consent was obtained from each participant prior to inclusion in the study data was kept confidential codified and analysed anonymously role of the funding partner the sponsor of the project did not play any role in the study design data collection analysis and interpretation or writing of this article results descriptive results a total of 1337 consented participants were retained in this analysis the majority were aged 2039 years and mostly made of women the mean age of the participants was 361 years men 402 years women 339 years the majority of fulani families did not plan to leave their present site 76 were planning to go elsewhere as against 224 for the bantus around the same area and 87 of the fulani were undecided as to whether they will depart from the present site table 1 represents characteristics by prevalence of hypertension and table 2 univariate and multivariate logistic regression for fulani men and women aged ≥20 years and table 2 represents the correlation of hypertension with sociodemographic and health characteristics gender burdens of sbp and dbp by 5year age interval are shown in figs 1 2 and 3 overweight and obesity overweight and obesity were rare though more prevalent amongst women than men significant differences in the bmi and wc subgroups were observed no significant gender differences in mean bmi but significant gender differences in mean wc the prevalence of overweight was 35 in men vs 69 in women and obesity was 16 in men against 25 in women while the prevalence of increased risk from wc was 38 in men vs 162 in women and substantially increaased risk 16 in men against 134 in women men had higher mean bmi than women and the majority of women of were underweight systolic and diastolic blood pressure mean sbp and mean dbp were 1279 and 804 mmhg respectively but higher in men than women sbp and dbp increased with advancing age in men and women although higher mean sbp and dbp values were observed in young men as compared to young women a sharp decrease in sbp was noted at 6064 years followed by a hike from ≥ 65 years in women the general prevalence of hypertension was 312 higher among fulani men than women severity of hypertension a total of 131 participants had isolated systolic hypertension and were graded into 1 2 or 3 and categorised as optimal normal high normal grade 1 hypertension grade 2 hypertension and grade 3 hypertension detailed distribution into categories the prevalence of hypertension among men was 365 normal high normal grade 1 hypertension grade 2 hypertension and grade 3 hypertension and the prevalence of hypertension among women was 287 normal high normal grade 1 hypertension grade 2 hypertension and grade 3 hypertension prevalence of hypertension among the fulbe was 32 and among the mbororo 308 grades 1 2 and 3 hypertension were higher among the fulbe than the mbororo and affecting participants aged ≥ 55 years more than the younger ones younger women were more likely to have normal blood pressure than younger men while women aged ≥ 60 years were more likely to have elevated blood pressure than men of the same age group awareness treatment and control of the 417 hypertensive participants 357 were newly diagnosed 10 were on antihypertensive medication in the past 2 weeks given by health professionals 9 had uncontrolled blood pressure and 20 had seen a traditional healer for elevated blood pressure in the past 12 months with 11 taking traditionalherbal remedy for high blood pressure at the time of study the majority of hypertensive participants were ≥ 40 years old married never went to adding salt to food adding sugar to teacoffee fh of diabetes fh of obesity vegetable and fruit intake currently employed physical activity and planning to migrate were not significant in univariate analysis in men and women or both analysed together blood pressure categories for men by five year age group blood pressure categories for women by five year age group multivariable logistic regression model all statistically significant factors in univariate analysis were included in the model adjusted for site and gender with wc replacing bmi to assess the effect of abdominal obesity further analysis by gender showed statistically significant results in women for fh of hypertension and in men insomnia results of multivariable logistic regression old age never attended school currentformer smoker fh of hypertension diabetic and sir from wc had higher odds were statistically significant also divorced separated and underweight had moderate statistical significance further analysis in men revealed having 812 children and insomnia to be statistically significant gender was not statistically significant irrespective of whether wc or bmi was considered no association was observed between hypertension and bmi among fulani women and with marital status in the separate multivariable regression analysis for men and women discussion there is a paucity of knowledge on the epidemiology of hypertension amongst the fulani population this study provides such data the epidemiology of hypertension in the fulani populations should be evolving as a consequence of their progressive shift from traditional lifestyles to transitional and western diet patterns sedentary life and movement to urban centres the mean bmi for both men and women was lower than the estimates from global statistics for cameroon and women and was lower than the recommended interval of 2123 kgm 2 for populations striving for optimal health 18 the fulani had a poor diet mainly made of carbohydrates sweetened beverages and sugarladen teas and worked for long hours in fields to feed numerous mouths having lost cattle their traditional means of livelihood this might be an indication of susceptibility to deleterious health especially among the married fulani women at reproductive age we observed a higher prevalence of sbp dbp and hypertension among men than women contrary to a study in ssa where women had a higher prevalence than men 19 and an increase in blood pressure with age as in the suriname health study and in ssa 2019 the prevalence of hypertension among the fulani and women in this study was in the range of the native indigenous community of central brazil 21 urban dwellers in cameroon 4 rural cameroonians 5 and ssa 19 but lower than that among the aboriginal nicobarese tribe of india in 2009 22 unlike urban dwellers in cameroon whose awareness of hypertension was higher 4 and rural cameroonians 5 this young rural fulani population had a low awareness of hypertension with no significant gender differences and unlike in brazil with significant gender differences 21 prevalence of hypertension in this rural population was high when compared to rural kenyans with a prevalence of 119 among men and 63 among women though gender prevalence was observed a twofold gender difference in prevalence was not seen as in rural kenya 23 rural settings and lifestyle have been cited as a protection factor to explain the low prevalence of cardiovascular risk and disease in african populations but the fulani population as well as the maasai in tanzania showed a high prevalence of hypertension amongst rural dwellers which may not confer the protective possibility we have reported an increase in the prevalence of ncd risk factors as a nomadic pastoral fulani transition to settled life as well as differences in anthropometric and lifestyle factors by ethnicity 10 the kenyan luo migration study also showed an increase in blood pressure following ruralurban migration 23 this high prevalence of grades 1 2 and 3 hypertension among the young fulani population with low awareness underpinned by an underresourced healthcare system may lead to future complications from hypertension disability morbidity mortality and a further increase in prevalence as this population changes from traditional nomadic lifestyle to settled life in urban conglomerates the prevalence of hypertension was higher among diabetic older participants as well as those who had never attended school or had a fh of hypertension as in brazil 21 we observed associations of hypertension with age male gender low level of education alcohol intake and overweight in univariate analysis as indicated by some studies 22 and with age lower levels of education tobacco use in multivariable logistic regression as in ssa including rural cameroon 52324 contrary to rural cameroon 5 being married was not a risk factor of hypertension among the fulani ageing comes with redistribution of body fat and hormonal changes in men and women and is associated with changes in lifestyle and dietary patterns 2526 this may explain the high prevalence of grades 1 2 and 3 hypertension with age the increase in blood pressure in women beyond 65 may be due to menopause which is accompanied by an increase in visceral adipose tissue decline in oestrogen and testosterone levels and higher circulating inflammatory profile 27 28 29 the ageing process also influences testosterone levels which have been shown to have antiinflammatory actions 30 at menopause the cardiocirculatory system is disrupted due to an end to ovarian function this often leads to a considerable decrease in endotheliumdependent vasodilation and in the emergence of other atherogenic factors oestrogen deficiency results in menopause associated with higher blood pressure and cvd risk in elderly women compared with the premenopausal stages 3132 a decrease in oestrogen concentrations and an increase in bmi may account for older women having inadequate control of blood pressure 33 hypertension has been shown to be the cause of some common complications during pregnancy like chronic hypertension preeclampsiaeclampsia gestational hypertension and postpartum hypertension which may give rise to maternal and perinatal complications 34 the majority of women in the study were at the reproductive age and the aforementioned complications during pregnancy may affect these women an upsurge in pregnancyrelated complications with underlying cause being hypertensive among the fulani women may be observed in the near future variation in the risk factors of hypertension with body fat proxies may be explained by the rarity of bmi defined overweightobesity and existence of sir from wc which was not uncommon among the fulani contrary to rural cameroon 5 bmidefined obesity was not a risk factor of hypertension among the fulani but bmidefined underweight was moderately protective to hypertension in this study other studies showed that high bmi is a risk factor for hypertension but we observed an association of high wc with hypertension as observed elsewhere 3536 the values for bmidefined overweight and obesity were too small in our study to show significant differences at 005 level other studies have shown differences in the pathophysiology and life course paths gene interaction with the environment contextual determinants social gradients 3738 and risk factors such research is warranted in the fulani population that is in the transitional phase the odds of being hypertensive from central obesity due to visceral adiposity were higher visceral adiposity assessed by wc is metabolically more active than peripheral fat responsible for bmi ethnicity genetics gender and age account for visceral adipose accumulation 39 elevated central obesity coupled with high prevalence of hypertension contributes to insulin resistance the fulani may have a higher risk of metabolic syndrome increasing the likelihood of type 2 diabetes high abdominal adiposity and low bmi play a key role in the susceptibility of south asians to metabolic syndrome 40 bmi assumes evenly distributed adipose tissue 39 and disregards heterogeneity in regional body fat disposition 41 the relationship between bmi and morbiditymortality is curvilinear very low bmi is associated with increased mortality and a surrogate for morbid conditions 42 43 44 however the relationship between hypertension and bmi was linear in this study high mortality was observed amongst the mbororo population 10 which at the same time had a higher prevalence of underweight women 10 in men insomnia was associated to hypertension as reported elsewhere 45 and having 812 children was moderately associated to hypertension many children may be a source of sleepless nights to parents especially fathers abnormal sleep upsets endocrine and metabolic performance and increases the sympathetic nervous system activity leading to increased risk of hypertension 45 we observed no association between low physical activity fruit and vegetable intake per week work status in the past 12 months frequently added salt to food at the table and frequently added sugar to teacoffee with hypertension despite previous reports on association 116174647 as a culinary tradition fulani especially men consume highly salted roasted meat and sugarladen local tea throughout the whole day meat intake especially red meat dietary sodium and sugar intake increases blood pressure and risk of hypertension 947 this may account for high prevalence of grades 1 2 and 3 hypertension and high mean values of blood pressure in men this may be due to the challenges involved with populationbased studies or subjectivity in the measure and classification of these risk factors unlike in our study low physical activity has been associated with hypertension 4849 cigarette smoking was associated with hypertension as shown by previous studies smoking is a modifiable risk factor for hypertension and important in intervention programs 5051 hypertension is a constellation of pathogenesis and pathophysiology causes involving lifestyle and environmental factors genetic predisposition disruption in the vasculature and neurohumoral synergy hypertension is associated with metabolic dysfunction and multisystem structural impairment which facilitate cardiovascular risk hypertension alone is the most important risk factor for stroke and a major factor of cognitive decline in later life rural poverty environmental degradation forced migrations and limited access to health have combined to create and perpetuate deleterious health consequences for aboriginal people from hypertension diabetes obesity cardiovascular disease interpersonal violence and suicide attributed to the increasing use of alcohol and drugs 52 53 54 hypertensive individuals as compared to normotensive individuals have a twofold increased risk of developing coronary artery disease fourfold increased risk of congestive heart failure and sevenfold increased risk of cerebrovascular and stroke 55 this is exacerbated by unresponsive and underresourced health systems and limited research among indigenous populations 56 an upsurge in morbidity and mortality from hypertension may be witnessed in the near future among the fulani population we are not aware of a previous study that highlighted the burden of hypertension in the fulani majority of whom are indigenous mbororo as more fulani move to urban centres and embrace westernised lifestyle the prevalence of hypertension in this population may increase future strategies to tackle hypertension should focus on culturally embedded prevention delay of the onset and the evolution of the silent disease process among the fulani conclusion the study provided data on occurrence and drivers of hypertension among the fulani as they undergo transition from traditional to transitory and modern lifestyles our findings indicate a high prevalence of hypertension in the rural fulani populations low awareness and control rural settings and life may not be protective for hypertension for this population the results of this study are critical for improving hypertension control and reducing cvd in this population with low healthcare accessibility underresourced healthcare system low education health care beliefs and practices at variance with the general population the fulani populations should benefit from early detection and culturally embedded appropriate interventions study strengths and limitations strengths of the study included a large sample size of the fulani population the majority of whom are indigenous mbororo population with no extant knowledge on ncd health risks we used standard conditions and automated devices to carry out the study in order to reduce measurement errors and bias that may arise from training multiple research teams our researchers were conversant with local fulani language which was often used to administer questionnaires bmi reliability in screening for cardiometabolic abnormalities could miss many atrisk adults in some racialethnic groups but in this study we combined bmidefined overweightobesity and wc in assessing hypertension risk further we used risk factor analysis centred on individuals as a preponderant scale in probing epidemiological questions and adequately explaining who is at risk who and the 2013 eshesc guidelines for definition and classification of hypertension were used the international definition of bmi subclasses irsir from wc was used limited research is done on the health of indigenous populations 56 and the study enriched the knowledge base of hypertension in fulani indigenous populations evidence from this study provides an opportunity for active surveillance diagnosis treatment of patients and capacity building as we noted low awareness of hypertension in this population the results allow for valuable ethnicspecific hypotheses and are vital for further research an important limitation of this study is the observational crosssectional design which precludes examination of multiple scale causal mechanisms and findings to allow for causal deductions mention should be made of unmeasured variables that may lead to residual confounding and measured confounders that can lead to misclassification as one of the limitations also agerelated associations to hypertension may also be due to lifestyle differences across age groups and not age trends the elderly were also transitioning from traditional to transitional and modern ways of life as well as the young this population though described as rural does not live in isolation they interact regularly with neighbouring urban populations in towns and are exposed to urban or semiurban life and could equally be considered as semiurban risk factor analysis does not explain why risks exist or differ within and between populations longitudinal studies are required to confirm the results risk factors are a continuum and categorisation disregards considerable contributions brought by these factors below threshold levels there are challenges to risk factor analysis due to the complexity of fundamental causes of diseases such as social biological behavioural and economic drivers poor hygiene infections overcrowding and gene interactions with environments and life course trajectories associated with poor health amongst indigenous populations 54 seasonal variations of blood pressure effect modification from socioeconomic status and indoor temperature changes on blood pressure were not assessed and might have influenced blood pressure readings and hypertension 57 the study did not differentiate fulanipeul people into fulbe and mbororo 10 who may have different epidemiological profiles though sharing the same ancestry our findings may not be generalizable to the larger population of fulani in some countries the majority of whom are nomadic with different disease and risk factor burdens moderated by contextual political socioeconomic and health systems fruit and vegetable quantification did not take into consideration servings eaten per day no detailed exploration on sleep difficulty was done additional files additional file 1 table s1 multivariable logistic regression for fulani men and women and both men and women additional file 2 table s2 univariate analysis by gender for fulani aged ≥ 20 years 2013 authors contributions nck conceived and designed the analytic strategy analysed the data and wrote the first and subsequent drafts jcm gn and gm reviewed the article all authors contributed to the design and subsequent drafts and read reviewed and approved the final manuscript competing interests the authors declare that they have no competing interests

background hypertension is a public health problem and the main contributor to cardiovascular mortality and morbidity little is known about hypertension among the minority diverse and socially disadvantaged 2324 million fulanipeul populations dispersed in west central and east africa undergoing a transition from traditional to transitional and modern lifestyle this study describes age and gender variations in blood pressure and drivers of hypertension among rural fulani population of cameroon methods we analysed populationbased crosssectional data collected in 2013 by standard methods from 1337 fulanipeul aged ≥ 20 years hypertension was defined as systolic blood pressure sbp ≥ 140 mmhg andor diastolic blood pressure ≥ 90 mmhg or current use of antihypertensive medication we elucidated the occurrence and drivers of hypertension by chisquare test students t test and univariate and multivariable logistic regression models results the prevalence of hypertension was 311 men 365 and women 287 systolic and diastolic blood pressure increased with age older women suffered more from grades 1 2 and 3 hypertension than older men old age divorcedseparated never attended school currentformer smoker family history fh of hypertension diabetic underweight and substantially increased risk from waist circumference were independently associated with hypertension insomnia and had 812 children were the only drivers of hypertension among men conclusion prevalence of hypertension was high awareness and control were low hypertension prevalence increased with age and was more prevalent among men than women older women experienced severe hypertension more than older men culturally embedded interventions are warranted to curb the high burden of hypertension among the fulani

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introduction the rate of hiv diagnosis among african american men who have sex with men is alarming although african americans represent only 13 of the us population 46 of hiv diagnoses from 2008 through 2011 were among african americans and msm accounted for the largest number of african americans living with hivaids 1 in 2011 the estimated rate of hiv diagnosis was 1128 per 100000 in african american men compared with 145 in white men 1 and there were more estimated hiv diagnoses in the maletomale contact transmission category in african american men than in white men despite the high rate of hiv diagnosis among african american msm limited progress has been made in developing efficacious interventions for this population a systematic review of behavioral interventions for msm published between 1988 and 2010 2 identified 33 studies of which nine met the criteria for evidencebased interventions but only one focused on african american msm that randomized controlled trial tested a group intervention that was implemented using a weekend retreat 3 averaged over 3and 6month postintervention assessments participants in the intervention were less likely to report unprotected insertive anal intercourse with casual male partners than were those in a waitlist comparison condition other recent rcts of hiv riskreduction interventions for african american msm have suffered from small samples short followup periods or nonsignificant results a rct testing an hiv riskreduction intervention for african american msm utilizing group sessions found no difference between intervention and control conditions on sexualrisk behavior 3 months postintervention 4 a pilot study testing a smallgroup intervention for hivpositive african american men aged 50 and older also found no difference in condom use between the hivsti riskreduction intervention and the control group 3 months postintervention 5 the interpretation of the results of rcts of hiv riskreduction interventions can be improved through the use of mediation analysis 67 which helps identify the aspects of an intervention responsible for its effect or lack of effect although several mediation analyses of hiv riskreduction interventions have been published 8 9 10 11 12 none focused on african american msm accordingly the mechanisms responsible for efficacy in successful interventions 3 and those responsible for lack of efficacy in unsuccessful interventions 4513 are largely unknown thus despite 30 years of research on hiv prevention we still do not understand the mechanisms that underlie behavior change in african american msm the population at highest risk for hiv in the us here we report the efficacy and mediation of an intervention to increase consistent condom use in african american msm the intervention developed based on the social cognitive theory 14 and the reasoned action approach 1516 integrated with extensive formative research with the target population 17 to ensure that it was culturally congruent was tested using a rct design a oneonone intervention was employed to allay the fear of those msm concerned about revealing their sexual involvement with men by virtue of participating in a group intervention a fear that may be particularly concerning in african american msm 1819 oneonone hiv riskreduction interventions have been efficacious in several rcts reducing selfreported sexualrisk behaviors and biologically confirmed stis 20 21 22 participants were randomized to being responsible for ourselves a threesession oneonone hivsti riskreduction intervention designed to increase consistent condom use or a threesession oneonone healthpromotion intervention which served as the attentionmatched control group we hypothesized that compared with the attentioncontrol group controlling for baseline consistent condom use the hivsti riskreduction intervention would increase consistent condom use during the 12month postintervention period which was the primary outcome to better understand our results we also report a mediation analysis on theoretical constructs hypothesized to predict consistent condom use methods institutional review boards at the university of pennsylvania and temple university approved this study because the centers for disease control and prevention coauthor was not engaged in direct contact with the participants the cdc deferred approval to the irb at the university of pennsylvania the study included african american msm irrespective of their hiv status and sexual orientation selfidentification potential participants were screened for eligibility men were eligible to participate if they were at least 18 years of age selfidentified as black or african american were born a male and reported having anal intercourse with a man in the previous 90 days men were excluded if they reported having anal intercourse with only one main male partner in the past 90 days or had participated in an hivsti riskreduction intervention in the past 12 months those eligible were invited to participate in project being responsible for ourselves designed to reduce the chances that men develop devastating health problems including cardiovascular diseases cancers and stis including hiv informed consent while blind to group assignment was required for participation participants were recruited in the philadelphia area through advertising in local newspapers read by african american msm through communitybased organizations serving african american msm through recruitment flyers posted at colleges universities parks bars and adult bookstores through facetoface recruitment at social events activities and parties where a large turnout of african american msm was expected and through the referrals of participants in a rct design computergenerated random number sequences were used to randomly assign participants to the bro hivsti riskreduction intervention or the attentionmatched healthpromotion intervention that served as the control condition using concealment of allocation techniques designed to minimize bias in assignment the biostatistician generated the random assignments the project director implemented the assignments participants were enrolled between april 2008 and march 2011 with all data collection completed by may 2012 participants who completed the preintervention questionnaire and attended intervention session 1 which occurred at the same visit were enrolled in the trial after enrollment data collectors but not intervention facilitators or participants were blind to group assignments we held the intervention and datacollection sessions at a university research center participants were compensated with 25 for the preintervention assessment 25 for each of the three intervention sessions 25 for the immediate postintervention assessment and 50 for each of the two followup assessments interventions the hivsti riskreduction and healthpromotion interventions were developed based on social cognitive theory 14 and the reasoned action approach 1516 integrated with extensive formative research 17 including focus groups and pilot testing social cognitive theory has been used to develop interventions to change sexualrisk behaviors 20 23 24 25 26 and a host of other health behaviors 27 28 29 30 31 most relevant here are the socialcognitivetheory constructs of outcome expectancy beliefs about the consequences of a specific behavior and selfefficacy peoples confidence that they can execute a specific behavior its emphasis on behavioral skills and its methods for increasing skills particularly practice with performance feedback the reasoned action approach is an extension of the theory of planned behavior 32 which itself is an extension of the theory of reasoned action 33 most relevant here are the reasoned action approachs emphasis on the importance of salient beliefs its notion that such beliefs may vary from population to population and from behavior to behavior and its methods to identify such populationspecific beliefs namely the use of qualitative research including focus groups identifying the salient beliefs in the population and then employing intervention activities designed to influence those populationspecific beliefs can result in an intervention that is both theoretically grounded and tailored to the population consistent with the reasoned action approach we conducted qualitative research seven focus groups with african american msm and one with representatives of cbos that serve african american msm to ensure the intervention was tailored to the population in addition we conducted three pilot tests of the interventions each intervention consisted of three 90min oneonone individual sessions implemented during 3 consecutive weeks by specially trained facilitators using standardized intervention manuals we utilized oneonone interventions to allay concerns some african american msm might have about revealing their sexual behavior with other men by virtue of participating in a groupbased intervention 1819 a concern expressed in the focus groups with african american msm and with representatives of cbos serving african american msm sessions 1 and 2 in each intervention included takehome assignments that the participants reviewed at the subsequent session the delivery of each intervention was tailored to the information that the participants provided during the sessions including information about behaviors relevant to the particular intervention the context in which the behaviors occurred and participants motivation for the behaviors the bro hivsti riskreduction intervention was designed to strengthen outcome expectancies expressed in focus groups with african american msm outcome expectancies that have been observed in other populuations including the hedonistic outcome expectancy that using condoms would not interfere with sexual enjoyment 9112324 34 35 36 37 the prevention outcome expectancy that using condoms prevents stis including hiv 2438 and the selfevaluative outcome expectancy that using condoms would make the man feel good about himself 92335 the intervention was designed to address aspects of selfefficacy identified in the focus groups including technicalskill selfefficacy to use condoms correctly without interfering with sexual enjoyment 83637 impulsecontrol selfefficacy to exercise the necessary control to use condoms even when sexually excited under the influence of alcohol or drugs or in the presence of other triggers for unsafe sex 112437 and skills and selfefficacy to negotiate condom use with sexual partners 83637 in addition it was designed to increase knowledge regarding the risk of acquiring or transmitting hiv and other stis and perceived vulnerability to hiv infection or reinfection with a different strain of hiv in session 1 a general introduction was designed to provide an overview create enthusiasm build trust and help the facilitator learn about the participant as an individual including his goals reasons for participating and sexual orientation selfidentification in the where do you draw the line activity participants discussed their sexualrisk behavior including when and where they had sex the types of sex in which they engaged and when they used and did not use condoms information used later to tailor activities to the participants participants completed a riskassessment activity on risky sexual practices an activity that focus groups said would help men to recognize their personal risk of hiv an activity also designed to identify factors that trigger participants sexualrisk behaviors this activity also provided information that allowed the facilitator to tailor the intervention to the unique risk and other characteristics of each man by focusing on the particular risk behaviors and contexts most relevant to him the intervention then focused on hivsti riskreduction knowledge and perceived risk of hivstis a mini lecture covered hiv sti symptoms transmission and prevention a discussion of the participants goals and dreams and how his sexualrisk behaviors might affect his goals for himself partners and community introduced the takehome assignment moving towards my goals which asked the participant to identify a behavioral goal based on his sexual risk identified earlier and to create a personal hiv sexualriskreduction plan he could employ to attain that goal in session 2 activities addressed participants outcome expectancies regarding condom use and the correct and consistent use of condoms it began with a review of the session 1 takehome assignment including participants barriers to achieving their personal behavioral goals and strategies to surmount the barriers with facilitators following a different protocol depending on whether the participant had completed the assignment a forced choice activity examined the participants beliefs about circumstances under which they should use condoms and the type of person who is vulnerable to hivsti the facilitator demonstrated on an anatomical model correct condom use and then the participant practiced the correct steps for condom use on an anatomical model the participants considered ways to make condom use fun and pleasurable and how alcohol and drug use might affect condom use the facilitator also asked the participant to list excuses that he and his partners give for not wanting to use condoms and to think of responses to neutralize the excuses a takehome assignment creating a relapse prevention plan asked the participant to imagine that he had been practicing safer sex and that he was suddenly faced with the triggers to have unsafe sex he had enumerated earlier the facilitator asked the participant to identify ways he might avoid such triggers and to suggest discreet ways to have condoms available when needed in session 3 the focus was on building knowledge selfefficacy and skills regarding negotiating condom use a discussion centered on the session 2 takehome assignment the facilitator and participants enacted roleplay scenarios about african american msm negotiating condom use in an insertive or receptive role with steady casual paying or female partners and under circumstances when they had slipped and had unsafe sex focusgroup participants had liked the scenarios saying they were realistic and employed relevant locations including gay acres where some men in the philadelphia area meet other men for sex the facilitator could adapt each roleplay scenario to suit the information the participant previously provided to ensure that the scenarios was as authentic as possible participants learned and practiced negotiation and communication skills using say no explain why provide alternatives and talk it out a fourstep strategy to communicate effectively their decision to use condoms and abstain from unprotected intercourse a virtual sex project interactive video allowed participants to select personally relevant risk situations for actors in hookup scenarios scenarios that focus group participants said were realistic the participants reviewed their personal hiv sexualriskreduction plan developed in session 1 and explored ways to overcome potential obstacles and to sustain behavior change in the commitment to safety activity the participants wrote a safersex promise letter to self partners and community that was mailed to them 6 weeks after the intervention to remind them of their commitment to be safe sexually the timeand dosagematched healthpromotion intervention provided a control for hawthorne effects reducing the likelihood that the hivsti riskreduction interventions effects could be attributed to nonspecific features including special attention 39 its activities while similar to those in the hivsti riskreduction intervention focused on increasing physical activity and fruitandvegetable consumption and decreasing fat consumption to reduce the risk of chronic diseases including heart disease hypertension stroke diabetes and certain cancersleading causes of morbidity and mortality among african americans 40 we considered employing african american msm as facilitators but the focus groups with representatives of cbos revealed that cbo staff who worked with african american msm were mainly african american or latino women of no particular sexual orientation selfidentification and the african american msm focus groups revealed no consensus on the desirable gender or sexual orientation of facilitators accordingly we employed facilitators irrespective of gender and sexual orientation the facilitators were 23 adults 2864 years of age twenty were african american two were latino and one was white about 565 had a masters degree which was the modal and median education 791 had previously facilitated hivsti riskreduction interventions 500 had previously facilitated healthpromotion interventions and 652 had previously worked with african american msm we hired individuals who had the basic skills to implement either of the two interventions after stratifying them by gender and age we randomly assigned them to be trained to implement one of the two interventions in this way we randomized facilitators characteristics across interventions hence reducing the plausibility of attributing any effects of the interventions to the facilitators preexisting characteristics 24 the facilitators received three 8hour days of training in their assigned intervention training that included a project overview the theoretical framework background information relevant to the assigned intervention and effective facilitation techniques including presentation style time management and nonverbal and verbal communication and stressed the importance of implementation fidelity the hivstiriskreductionintervention training also covered transgender issues sexual identity development and tops versus bottoms during the training the trainers modeled the intervention activities the facilitators learned their assigned intervention practiced implementing it received feedback from each other the trainers and investigators and created common responses to potential issues that might arise during implementation besides the facilitator training we provided facilitators and all staff who might have even incidental contact with the participants two 8hour days of sensitivity training on the knowledge skills and perspectives necessary to work effectively with african american msm we employed several quality assurance procedures a facilitator supervisor met with the facilitator before each session reviewing the materials answering any questions reviewing the sessions purpose and reiterating any specific points that the facilitator should emphasize in the session when the session ended the supervisor reviewed the facilitators log sheets indicating the extent to which the facilitator completed the activities and debriefed him or her addressing concerns and providing suggestions to address implementation issues the supervisor also reviewed the digital tape recordings of the sessions and subsequently provided performance feedback to the facilitators and retraining if necessary periodically the supervisor held group meetings with all the facilitators to discuss implementation issues and to fashion common responses assessments the participants completed confidential questionnaires via audio computerassisted selfinterviewing technology which provided both audio and video presentation of the questions and response options on a laptop computer sexualrisk behaviors theoretical constructs sociodemographic variables and healthpromotion behaviors and theoretical constructs were assessed preintervention and 6 and 12 months postintervention the theoretical constructs were also assessed immediately postintervention we pilot tested the paper version of the questionnaire with 217 men to ensure that the questions were clear and appropriate for the target population and then programmed it for acasi and pilot tested it with 16 men to identify and correct any programming errors the primary outcome was consistent condom use a binary variable reflecting whether the participant reported using a condom every time he had anal or vaginal intercourse in the past 90 days it was based on a comparison of the sum of the reported anal and vaginal intercourse acts in the past 90 days and the sum of the reported condomprotected anal and vaginal intercourse acts in the past 90 days men who reported at least one intercourse act and whose number of reported protected acts equaled their number of acts were coded as practicing consistent condom use men who reported at least one intercourse act and whose reported number of protected acts was less than their number of acts were coded as not practicing consistent condom use a widely used measure in hiv prevention trials 41 considerable evidence indicates that selfreported consistent condom use is associated with a reduced risk of sti including hiv 42 43 44 45 46 secondary outcomes included proportion of condomprotected intercourse acts unprotected sexual intercourse multiple sexual partners insertive anal intercourse and receptive anal intercourse the proportion of condomprotected intercourse acts was assessed in men who reported at least one intercourse act the denominator was the sum of reported anal and vaginal intercourse acts in the past 90 days and the numerator was the sum of condomprotected anal and vaginal intercourse act in the past 90 days unprotected intercourse was a binary variable indicating whether the participants reported having vaginal or anal intercourse in the past 90 days without using a condom it was constructed by subtracting the sum of the condomprotected anal and vaginal intercourse acts from the total number of anal and vaginal intercourse acts in the past 90 days if the difference was one or greater the participant was coded as having unprotected intercourse if the difference was zero or if the person reported no vaginal or anal intercourse in the past 90 days the person was coded as not having unprotected intercourse participants whose sum of anal and vaginal intercourse partners in the past 90 days was 2 or greater were coded as having multiple partners and those who reported having 0 or 1 anal and vaginal intercourse partners in the past 90 days were coded as not having multiple partners insertive anal intercourse was a binary variable indicating whether the participant reported having insertive anal intercourse with a man in the past 90 days receptive anal intercourse was a binary variable indicating whether the participant reported having receptive anal intercourse with a man in the past 90 days outcome expectancies table 1 presents the number of items response format and cronbachs alpha for the theoretical constructs we assessed three types of outcome expectancies regarding condom use hedonistic outcome expectancy concerns the belief that the use of condoms will not interfere with sexual enjoyment 9 11 23 24 3437 47 48 it was measured with a scale used in previous intervention trials 1137 to which two items were added based on qualitative research the new scale correlates highly with the original scale r 098 p 00001 an example item is when a condom is used sex is more fun prevention outcome expectancy the belief that condoms can reduce the risk of hiv other sti and pregnancy was assessed with a scale used in previous research 2434363848 an example item is condoms help prevent aids selfevaluative outcome expectancy the expected reactions of pride as a consequence of using condoms 92335 was measured with a scale used in previous research 49 an example item is i feel good about myself when i use condoms selfefficacy we assessed four types of selfefficacy regarding condom use availability selfefficacy the mans belief that he can have condoms available when needed 1124 was assessed with a scale used in previous research 24 an example item is it is easy for me to have a condom with me all the time negotiation selfefficacy the mans belief that he can convince his partners to use condoms 82437 was assessed with a scale used in previous research 2437 to which two items were added the new scale correlates highly with the original scale r 095 p 00001 an example item is i can get my partner to use a condom even if he or she doesnt want to technical skill selfefficacy the mans belief that he knows how to use condoms 8243637 was assessed with a scale that predicted intention to use condoms in the pilot survey of african american msm r 043 p 00001 an example item is i can use a condom even if the room is dark impulsecontrol selfefficacy the mans belief that he can control himself sufficiently when sexually aroused to use a condom 112437 was measured with a scale used in previous research 2437 an example item is if i am sexually aroused i can stop before sex to use a condom hivsti riskreduction knowledge regarding transmission of hiv risk of different behaviors and correct use of condoms was assessed with a modified version of an index used in previous research 37 one item on limiting partners was added condomuse knowledge is a subscale of the hivsti riskreduction knowledge index consisting of items on the correct use of condoms 37 we also assessed two theoretical constructs that though not targeted by the intervention are constructs in our theoretical framework 1550 subjective norm is the mans belief regarding whether people important to him would approve of his using condoms 51 an example item is most people who are important to me would think it is okay for me to use a condom condomuse descriptive norm is the mans belief regarding his closest friends frequency of using condoms 51 an example item is on average how often do your 5 closest friends use condoms when they have sexual intercourse data collectors received two 8hour days of training that included modeling of datacollection procedures and practice with performance feedback we employed procedures used in previous trials to increase the validity of selfreported sexual behavior 5253 for instance to facilitate participants recall we asked them to report their behaviors during a brief period posted the dates ratings on the likert scales could range from 1 to 5 except for condomuse descriptive norm where the ratings could range from 1 to 5 the score was the mean of the ratings except for hiv riskreduction knowledge and condom use knowledge where the score was the sum of the number of items correctly answered alpha is cronbachs coefficient alpha for the postintervention assessment of the construct which was analyzed as the potential mediator comprising the period on newsprint gave them calendars highlighting the period and instructed them to record some events that occurred during the period to reduce the likelihood that participants would minimize or exaggerate we utilized acasi which has been shown to increase reports of socially undesirable behaviors as compared with facetoface interviews and pencilandpaper surveys which may reflect more accurate responding 5455 in addition we stressed the importance of responding honestly informing them that their responses would be used to create programs for african american msm like themselves and that we could do so only if they answered the questions honestly we assured the participants that their responses would be kept confidential 56 and that code numbers rather than names would be used on the questionnaires participants signed an agreement pledging to answer the questions honestly a procedure that has been shown to yield more truthful selfreports 57 sample size and statistical analysis a statistical power analysis was performed to calculate the sample size required to detect a clinically significant effect of the hivsti riskreduction intervention on the primary outcome consistent condom use compared with the attentioncontrol group in the pilot survey we found that 42 of the african american msm reported consistent condom use over all of their anal and vaginal intercourse acts in the past 90 days we selected an absolute increase of 14 points in consistent condom use as a clinically and substantively important effect size assuming a twotailed test a 005 20 attrition and a 14 increase in consistent condom use from 42 in the control group to 56 in the hivsti intervention group with n 594 men enrolled in the trial the estimated statistical power was 84 58 we used descriptive statistics to summarize the participants at baseline on sociodemographic variables and v 2 test and logistic regression to analyze attrition the efficacy of the hivsti riskreduction intervention averaged over the 6and 12month followups compared with the healthpromotion intervention was tested using logistic generalizedestimatingequations adjusting for the longitudinal repeated measurements on participants 5960 and controlling for baseline measure of the outcome the models were fit and contrast statements specified to obtain estimated odds ratios and their corresponding 95 confidence intervals robust standard errors were used and an independent working correlation matrix was specified the models included timeindependent covariates baseline measure of the outcome intervention condition and time in addition we included as covariates sexual orientation selfidentification selfreported hiv status and age group in analyses in which they were statistically significant we report estimated intervention standardized effect sizes averaged over the two followup assessments calculated by transforming the odds ratios using the cox transformation 61 models assessing whether the efficacy of the intervention differed between the two followups included the baseline measure of the criterion intervention condition time and the interventioncondition 9 time interaction the analyses were performed using an intenttotreat model with participants analyzed based on their intervention assignment regardless of the number of intervention or datacollection sessions they attended analyses were completed using sas v9 we assessed mediation using a productofcoefficients approach 762 where the a path denotes the effect of the intervention on a potential mediator at the immediate postintervention assessment the b path denotes the effect of the potential mediator on consistent condom use averaged over the 6and 12month postintervention assessments and the product of a and b quantifies the mediated effect of the intervention mediation is determined by testing whether the ab product differs significantly from 0 each theoretical construct was evaluated separately for mediation of effects of the intervention on the primary outcome consistent condom use we estimated the a paths using linear regression models on theoretical constructs at the immediate postintervention assessment adjusting for baseline of the theoretical construct and consistent condom use we estimated the b paths using gee logistic regression models with time intervention condition and baseline of the theoretical construct and consistent condom use as covariates estimated mean differences and 95 ci are reported for the a paths estimated odds ratios and 95 ci are reported for the b paths estimated ab products and because the distribution of a product is nonnormal asymmetric 95 confidence intervals calculated using the bootstrap quantile method 62 with 2000 replicates are reported the p 005 twotailed statistical significance criterion was used mediation analyses were conducted in r version 2151 63 results characteristics of the sample table 2 presents characteristics of participants by condition the participants were 595 african american msm 295 in the hivsti riskreduction intervention and 300 in the healthpromotion control intervention participants age ranged from 18 to 69 years only 285 were employed and 484 had completed high school almost all had been tested for hiv and of those tested 295 said they were hiv positive there were several indicators of high risk 489 had a history of childhood sexual abuse victimization 371 had a history of intimate partner violence victimization 445 were alcohol dependent and 518 had a history of incarceration a large minority reported substance use in the past 90 days including marijuana and crack cocaine about 437 said they had intercourse with a woman in the past 90 days about 406 selfidentified as gay 413 selfidentified as bisexual 105 said they were on the down low and 76 selfidentified as straight as shown in fig 1 attendance at the 3 intervention sessions was excellent 594 or 998 attended intervention session 1 561 or 943 attended intervention session 2 and 554 or 931 attended intervention session 3 a high percentage of participants reported completing takehome assignment 1 and 2 with a higher percentage of hivsti riskreduction compared with control participants reporting completing assignment 1 on average the facilitators reported completing 980 of the intervention activities high percentages of participants completed the postintervention assessments 553 or 929 completed the immediate posttest 505 or 849 completed the 6 months postintervention followup 503 or 845 completed the 12 months post intervention followup of the original 595 538 or 904 attended at least one of the two followups the hivsti riskreduction and control conditions did not differ significantly in the percentage attending at least one followup baseline measures of outcomes did not predict attending at least one followup nor did facilitators sex age or experience working with african american msm in addition none of the baseline sociodemographic characteristics predicted returning for at least one followup with three exceptions age was positively associated with returning for followup the older the participants were the more likely they were to return men who had stable housing were more likely to return than were those who had unstable housing among men who reported being tested for hiv those who said they were hiv positive were more likely to return than were men who said they were hiv negative effects of the bro hivsti riskreduction intervention on sexual behaviors table 3 presents the descriptive statistics for sexual behavior outcomes by intervention condition and assessment period table 4 presents estimated intervention effects unadjusted and adjusted for baseline response and other significant covariates irrespective of condition selfreported consistent condom use in the past 90 days increased significantly averaged over the 6and 12month followup compared with baseline the hiv sti riskreduction and healthpromotion interventions did not differ significantly on consistent condom use averaged over the 6and 12month followup assessments adjusting for baseline consistent condom use irrespective of condition participants were less likely to report unprotected intercourse multiple partners insertive anal intercourse and receptive anal intercourse averaged over the 6and 12month followups compared with baseline men in the hivsti riskreduction intervention were less likely to report having receptive anal intercourse during the followup period than were their counterparts in the healthpromotion intervention adjusting for baseline consistent condom use and sexual orientation selfidentification the hivsti riskreduction and healthpromotion interventions did not differ significantly on proportion of condomprotected intercourse acts unprotected sexual intercourse multiple partners or insertive anal intercourse during the followup period the intervention x followup interactions were nonsignificant indicating that efficacy of the intervention did not differ significantly at 6month compared with 12month followup for any outcome in addition the interventions efficacy did not differ by the participants hiv status or the facilitators sex age or experience working with african american msm mediation analysis of the intervention effect on consistent condom use the means and standard errors for the theoretical constructs by intervention condition and assessment period are presented in table 5 the results of the mediation analysis are presented in table 6 compared with the healthcontrol intervention bro significantly increased seven of the nine theoretical constructs it targeted adjusting for baseline of the theoretical construct and consistent condom use condomuse hedonistic outcome expectancy prevention outcome expectancy selfevaluative outcome expectancy technicalskill selfefficacy and impulsecontrol selfefficacy hivsti riskreduction knowledge and condomuse knowledge it did not significantly increase condomuse availability or condomuse negotiation selfefficacy the b path was significant for two of the nine theoretical constructs the intervention targeted condomuse negotiation selfefficacy and condomuse impulsecontrol selfefficacy and one construct the intervention did not target condomuse descriptive norm only one theoretical construct the intervention targeted condomuse impulsecontrol selfefficacy had a significant ab product indicating bro had an indirect effect increasing consistent condom use through increased condomuse impulsecontrol selfefficacy the intervention effect is averaged over the 6month and 12month postintervention assessments all adjusted analyses adjust for baseline of the criterion proportion of condomprotected insertive anal intercourse and receptive anal intercourse also adjusted for sexual selfidentification multiple partners also adjusted for selfreported hiv status insertive anal intercourse also adjusted for age group d is the effect size estimate in standard deviation units based on cox transformation of the odds ratio 61 gee generalized estimating equations msm men who have sex with men discussion contrary to expectation the present study did not support the hypothesis that the hiv riskreduction intervention would increase consistent condom use in african american msm compared with the attentionmatched control group although consistent condom use did increase significantly in the sample as a whole the increase was not greater in the hiv riskreduction intervention the hiv riskreduction intervention reduced receptive anal intercourse compared with the control group a behavior tied to elevated risk of incident hiv infection 64 but did not increase the proportion of condomprotected intercourse or decrease multiple partners or insertive anal intercourse in finding limited intervention effects on sexualrisk behavior the present study is similar to other studies on african american msm for instance the earliest trial to test an intervention with african american msm found no difference in sexual behavior between the intervention and a notreatment control group at 12or 18month followup 13 two more recent studies found no difference in sexual behavior between intervention and control groups at 3month followup 45 although a trial found that the many men many voices intervention reduced one sexualrisk behavior unprotected insertive intercourse with causal partners averaged over 3and 6month postintervention followups the intervention did not reduce unprotected anal intercourse with main or causal partners receptive intercourse with main or causal partners unprotected insertive anal intercourse with main partners or the number of partners compared with the waitlist control group 3 consistent with several other trials we also found sexualrisk behaviors decreased over time in the sample as a whole 4925 consistent condom use increased and multiple partners insertive anal intercourse and receptive anal intercourse decreased over time we would speculate about a couple factors that may account for the overall risk reduction first men who agreed to participate in the study may have been interested in reducing their sexualrisk behaviors which both prompted their decision to participate and subsequently to reduce their risk behaviors in the postintervention period second the repeated completion of the riskbehavior assessments may have constituted an intervention that prompted the men to think about their behavior and subsequently act to reduce their sexual risks 9 while there have been calls for mediation analyses of hiv riskreduction interventions 65 we are unaware of any other trial with african american msm that has reported a mediation analysis indeed most hiv riskreduction intervention trials targeting african american msm have not reported whether the intervention affected theoretical constructs hypothesized to account for the mechanism of its impact 3513 one trial found that the intervention did not change socialcognitivetheory constructs compared with the control group 4 the present mediation analysis provided insight into why the intervention did not affect the primary outcome of consistent condom use generally mediation analysis provides information on two sets of relationships which potential mediators were changed by the intervention and which potential mediators were associated with changes in the outcome in the present analysis the intervention changed seven potential mediators constructs from social cognitive theory and the reasoned action approach the intervention targeted however of these only one condomuse impulsecontrol selfefficacy was related to consistent condom use and consequently was the only significant mediator on the other hand the intervention did not increase condomuse negotiation selfefficacy which was significantly related to consistent condom use given that neither the participants significant referents nor their closest friends attended the intervention it is not surprising that the intervention also did not affect the two normsrelated constructs subjective norms and descriptive norms though one of them descriptive norms predicted increased consistent condom use theoretical constructs are from the immediate postintervention assessment alpha path the effect of the intervention on the theoretical construct is adjusted for baseline consistent condom use and the theoretical construct beta path the relation of the theoretical construct to consistent condom use 6 and 12 months postintervention is adjusted for intervention and baseline of consistent condom use and mediator ci is confidence interval aci is asymmetric confidence interval based on bootstrap quantile method with 2000 replicates the intervention increased hedonistic outcome expectancy selfevaluative outcome expectancy and condomuse technical skills selfefficacy and previous research has tied these constructs to condom use or condomuse intention in a variety of populations including msm 93566 african american adolescents 36 south african adolescents 67 college students in south africa 68 college students in the us 69 and flemish high school students 70 for instance a study found that hedonistic outcome expectancy and selfevaluative outcome expectancy predicted sexualrisk behavior following an intervention with msm 9 what is puzzling is why condomuse hedonistic outcome expectancy selfevaluative outcome expectancy and technical skills selfefficacy did not predict consistent condom use in the present trial the results of the mediation analysis have implications for developing efficacious interventions for african american msm enhancing the existing skillbuilding activities or adding additional activities to bolster selfefficacy to negotiate condom use might increase bros efficacy another implication is that enhancing effects on descriptive norms might increase the efficacy of interventions for african american msm more generally to be sure pursuing increases in descriptive norms would require a different intervention strategy oneonone interventions or interventions with groups of strangers are unlikely to affect descriptive norms because there is little reason for participants to perceive that their closest friends condom use has changed since the friends have not received any intervention more likely to affect descriptive norms is intervening not only with individual african american msm but also with their closest friends by so doing it may be possible to change the friends behaviors which would affect the participants descriptive norm which would in turn increase consistent condom use particularly if the intervention also increased condomuse negotiation selfefficacy and impulsecontrol selfefficacy the limitations of this study should be considered behavior was measured with selfreports which may be subject to social desirability bias although the use of acasi may have mitigated potential problems with selfreports objective indicators of sexualrisk behavior such as biologically confirmed stis would have improved the study in addition the findings may not generalize to all african american msm because participants were not randomly selected the reliability of the theoretical constructs ranged from 068 to 093 higher reliability would have increased the statistical power for the mediation analyses hence we may have underestimated mediation 71 a limitation of the mediation analyses is that they are correlational evidence from factorial experiments manipulating intervention components and putative mediators would be more cogent though admittedly difficult to implement in practice 72 there were also important strengths behaviorchange theory was integrated with extensive formative research to develop an intervention that was both theoretically grounded and culturally congruent a rct design and a doseand modalityequivalent control intervention controlling special attention was employed the retention rate was relatively high and did not differ by intervention arm mediation analysis was used to suggest an alternative intervention approach conclusion given the paucity of efficacious hiv riskreduction interventions for african american msm the population at highest risk for hiv in the us this study contributes to the literature by suggesting new directions for intervention research with this population consistent with several other trials we found scant evidence that the intervention reduced sexualrisk behavior although it reduced receptive anal intercourse and metaanalytic evidence indicates msm who engage in receptive anal intercourse only or both receptive and insertive anal intercourse are over six times more likely to develop an incident hiv infection compared with msm who engage in insertive anal intercourse only 64 it did not increase consistent condom use the primary outcome or affect any other behavioral outcome however the trial employing a highrisk sample that reported many syndemic psychosocial conditions including childhood abuse victimization intimate partner violence and alcohol dependency 73 went beyond previous trials in drawing attention to the mediating mechanism in a theorybased intervention descriptive norm the mans belief that his closest friends are using condoms was a significant predictor of consistent condom use in the mediation analysis a finding that raises the possibility that interventions designed to increase descriptive norms might be efficacious with african american msm interventions such as the one that we employed focusing exclusively on msm and not their close friends are unlikely to change msms perceptions of their close friends condom use an efficacious approach might be to incorporate msm and their close friends in interventions with the goal of changing descriptive norms which in turn would increase safer behavior including consistent condom use by conducting research with this alternative strategy it may possible to reduce the high rates of new hiv infections in african american msm

we examined the efficacy and mediation of being responsible for ourselves bro an hivsti riskreduction intervention for african american men who have sex with men msm the population with the highest hivdiagnosis rate in the us we randomized african american msm to one of two interventions bro hivsti riskreduction targeting condom use or attentionmatched control targeting physical activity and healthy diet the interventions were based on social cognitive theory the reasonedaction approach and qualitative research men reporting anal intercourse with other men in the past 90 days were eligible and completed preintervention immediately postintervention and 6 and 12 months postintervention surveys of 595 participants 503 85 completed the 12month followup generalizedestimatingequations analysis indicated that compared with the attentionmatched control intervention the bro intervention did not increase consistent condom use averaged over the 6and 12month followups which was the primary outcome although bro did not affect the proportion of condomprotected intercourse acts unprotected sexual intercourse multiple partners or insertive anal intercourse it did reduce receptive anal intercourse compared with the control a behavior linked to incident hiv infection mediation analysis using the productofcoefficients approach revealed that although bro increased seven of nine theoretical constructs it was designed to affect it increased only one of three theoretical constructs that predicted consistent condom use condomuse impulsecontrol selfefficacy thus bro indirectly increased consistent condom use through condomuse impulsecontrol selfefficacy in conclusion although bro increased several theoretical constructs most of those constructs did not predict consistent condom use hence the intervention did not increase it theoretical constructs that interventions should target to increase african american msms condom use are discussed

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introduction the role of internet and smartphone ubiquity in health care improvement particularly in a resourceconstrained developing world has gained global interest in the past decade 1 under the umbrella terms of electronic health and mhealth researchers have investigated possible ways in which the proliferation of smartphone devices and internet platforms can be used to improve health education and health outcomes in the developing world 2 in developed countries such as the united states and japan more than 70 of the population has reported the use of internet as the primary source of information especially for selfcare management similarly in developing countries the use of internet for accessing health information has been rapidly increasing 34 this trend is not surprising considering the tech savviness of young adults and the easy accessibility to the internet however these webbased health interventions or programs cannot be executed as technical programs in a vacuum ignoring the complex contexts in which they are implemented 5 therefore in digital health literacy it is important that consumerfocused electronic resources are designed such that they are aligned with the literacy levels of the intended audience ehealth literacy is identified as an important skill set for ehealth users and it refers to the ability of an individual to seek find understand and appraise health information from electronic resources and apply such knowledge to addressing or solving a health problem 6 the ehealth literacy scale consists of several levels which show the set of skills that are required to effectively engage the use of information technology for improving health the lower levels of the scale comprise operational and navigational skills while the higher levels require the ability to choose and critically evaluate the available information 7 ehealth literacy can help developing countries access webbased health information resources effectively studies examining ehealth literacy 4 8 9 10 11 have largely been performed in developed countries such as the united states finland china and japanwith particular emphasis on young adults and college students however only a few studies have identified an association between ehealth literacy and health behaviors while even fewer studies have examined the association between ehealth literacy and the health behaviors of young adults in developing countries 12 despite the increasing use of the internet as a source of health information in developing countries ehealth literacy is an unexplored entity which has been created and refined by the developed world 13 while technologybased health information is being proposed as the solution to elevate the health literacy levels of the pakistani population 14 there is very limited investigation of the ehealth literacy of the health seekerswith focus only on those seeking healthrelated education 15 the latest national human development report of pakistan 16 highlighted that only little is known about the health literacy and the health behaviors of pakistani youthsespecially among those who are welleducated and frequent users of the internet therefore in this study we aimed to examine the association between the patterns of internet use for seeking health information and the ehealth literacy of university students in pakistan further we investigated the possible association of ehealth literacy with the health behaviors of these university students methods measurements a quantitative crosssectional design was used to conduct this research students enrolled in the universities had to meet the english language requirements prior to admission as the mode of instruction in the anonymous webbased survey was english therefore all the participants had to comprehend and answer the questions in english the survey instrument was developed based on a review of previous studies consisting of validated items 81718 the questionnaire consisted of the following key items 1 demographic data and patterns of internet use this item consisted of questions on participant age gender and education level the internet use patterns were explored by asking questions on the frequency of internet use for browsing health information and common healthrelated topics these questions were designed on the basis of previous studies exploring the patterns and reasons for seeking webbased health information 17 finally participants rated their frequency of using google and other social media platforms as a venue for seeking health information on a scale of 1 to 5 the participants rated the following social media platforms google whatsapp twitter snapchat instagram and facebook 8 2 perceived ehealth literacy ehealth literacy was measured using the english version of the ehealth literacy scale 18 which is an 8item instrument measured on a 5point likerttype scale ranging from 1 to 5 the eheals scores ranged from 8 to 40 wherein a high score indicates high perceived ehealth literacy and a low score indicates low perceived ehealth literacy 3 health behaviors physical activity was assessed through questions on the weekly frequency of moderate physical activity supplement intake was assessed through questions on the use of dietary supplements for those who used dietary supplements further information was requested on the type of supplement used the ethical approval for this study was obtained from the human research ethics committee of queensland university of technology this study has been reported in accordance with the checklist for reporting the results of internet esurveys 19 survey validation and administration a pilot test of the survey was completed with a sample of 14 undergraduate university students in pakistan to ensure that the target audience understood the meaning of each question and response the pilot feedback was used to edit the survey accordingly the revised survey was administered using the webbased key survey tool we believed that a webbased survey would be appropriate for this study because responders to such surveys can use the computer and internet effectively the identified eligible participants were sent the link to the webbased survey via their university group email and 1 reminder was sent to give them the opportunity to complete the survey if they had not already done so the participation in this survey was voluntary and no incentives were offered for participation the survey remained open for 6 weeks data analysis a data matrix was produced from the completed questionnaires by using sas 94 for windows qualitative variables were expressed as numbers and percentages the percentages were calculated based on the valid cases only the chisquare test was performed to determine the association between the variables p≤05 was considered significant the total scores of the eheals were summed to a range from 8 to 40 with high scores representing high selfperceived ehealth literacy we divided the eheals score into one of the 2 categories relative to the median group value we did this in accordance to that done in previous studies 48 that used eheals to analyze the associations between the frequency of seeking health information ehealth literacy and health behaviors results participants demographic data and internet use patterns of the 900 eligible students invited to participate 559 students logged onto the webbased questionnaire platform and 505 students completed the questionnaire by providing all the demographic information thus 505 students were included in the final analysis of these 505 students 211 students were females 881 of the participants were younger than 25 years and 853 of them were pursuing an undergraduate degree we found that 796 of the participants were identified as frequent users of the internet 111 of the participants reported using the internet for searching healthrelated information almost every day while 461 used it once a week or more internet use patterns and ehealth literacy with regard to ehealth literacy only 399 participants who used the internet for finding healthrelated information answered the 8 standard eheals questions the median eheals score was 29 and this value did not vary with gender or the education level based on the eheals score the participants were divided into 2 groups the first group had scores higher than the median eheals score while the second group had scores lower than the median eheals score the most common type of healthrelated information searched by the participants was that related to healthy lifestyle this was common among both high and low ehealth literacy groups however those with high perceived ehealth literacy reported that they used the internet over the last 12 months more often for finding people with similar health issues google was the most widely used search engine of the 401 participants who reported frequent use of google 365 used google to obtain healthrelated information with regard to other social media platforms 640 of the participants who used facebook 596 of the participants who used wikipedia and 150 of the participants who used twitter reported that they used these platforms to obtain or share healthrelated information the use of any of these specific social media platforms was not associated with the perceived ehealth literacy health behaviors and ehealth literacy overall 259 of the participants reported engaging in moderate physical activity more than five times a week while 235 of the participants engaged in moderate physical activity less than once a week the perceived level of ehealth literacy was not associated with the reported levels of physical activity some form of supplement was taken by 487 of the participants vitamin d supplements were reported as the most commonly used supplement dietary supplement use was significantly associated with gender with females more likely to use supplements as compared to males the perceived level of ehealth literacy was not associated with the reported supplement use patterns discussion to our knowledge this study is one of the very few studies that have examined the ehealth literacy levels among young adults in developing countries and the association of ehealth literacy with internet use patterns and health behaviors after controlling for the sociodemographic variables we found that ehealth literacy was not associated with health behaviors such as physical activity and dietary supplement intake although there is evidence that eheals may consist of several subscales we analyzed the eheals as a unidimensional factor following hydes recommendation 20 therefore our analysis considers the full eheals which also allows us to compare our results with those of other studies 8 our population consisted of university students pursuing an engineering degree in pakistan the median eheals score in our study was similar to that reported among young adults seeking a healthrelated degree in pakistan 15 further the median eheals score in this study was comparable to that reported previously in an adult population in the united states slightly higher than that reported in the adult populations of korea iran and kuwait and much higher than that reported in an adult population in japan 4 8 9 10 similar to that reported in previous studies most sociodemographic variables examined in this study were not significant predictors of ehealth literacy 4 8 9 10 as reported previously 410 it is possible that the geographical location and cultural and language barriers could affect the eheals scores because of limited availability of healthrelated information in languages other than english this may not be the case for the population in this study as english is the official medium of instruction in the pakistani university educational system and participants in this study are frequent users of the internet unlike the findings of recent studies from the united states and japan 421 that showed a significant association between eheals scores in young adults and health behaviors such as exercise we found no association between eheals scores and the reported physical activity levels in pakistan very few studies have investigated how digital health literacy can improve health behaviors in 2018 saeed et al 22 evaluated the digital health literacy of patients with type 2 diabetes in lahore pakistan and they reported that patients with high socioeconomic status agreed that access to digital medical content via smartphones and tablets helped them improve their health however only the use of internet and the high ehealth literacy levels among educated young adults cannot translate into health behavior improvements if the communities that they live in lack the needed infrastructure to facilitate the required physical activity programs it is important to note that developing countries such as pakistanunlike japan and the united stateslack culturally suitable infrastructure and civic amenities such as playgrounds parks and gyms 2324 the lack of such facilities inhibits the realization of positive health behaviors and encourages indoor sedentary lifestyles 16 we also found that there was no significant association between ehealth literacy and dietary supplement intake recent studies from developed countries have reported internet as the primary source of information to inform attitudes toward the use of dietary supplements among young adults 2526 recent evidences have shown that ehealth literacy influences the food choices of adolescents 27 in the last few years pakistan has witnessed a rise in the demand for nutraceuticals dietary supplements attained a compound annual growth rate of 14 in 2016 28 these nutraceuticals are mostly used by the educated population 29 in light of these interesting preliminary trends future research should focus on the effects of the patterns of internet searches and social behaviors on supplement intake the aspects around ehealth literacy and its association with health behaviors such as dietary supplement use have not been reported in any developing country to date to the best of our knowledge this study presents a valuable contribution to establish evidence in particular for a country facing pressures to improve health literacy and public health outcomes this study has several limitations first the participants were recruited from a convenience sample of university students in pakistan thus the relationships assessed may have been biased because of the potentially nonrepresentative nature of this sample however this approach was viable because it provided us with a sizable sample in a reasonable amount of time for a population wherein such investigations have not been performed previously our study presents the needed ground to build on future studies that explore the ehealth literacy of broad population groups so that the findings can be applied to other developing countries second as in previous studies health behavior and ehealth literacy were examined using a selfadministered questionnaire thus inaccuracies in estimating the health behavior and ehealth literacy level were unavoidable and data of some of the participants were missing in addition we did not investigate the specific health status of the participants or whether they were searching for healthrelated information for another family member moreover this study was limited to only examining supplement use as a dietary behavior future studies should explore additional dietary behaviors and the context for using the internet for healthrelated information our findings revealed high eheals scores among the participants this high confidence shown by the university students presents a myriad of opportunities to better engage people digitally and conveniently as internet is being increasingly used as a source of health information further research is needed to identify the mechanisms linking ehealth literacy with health behaviors toward designing contextually effective strategies for improving selfcare in developing countries authors contributions at and sk conceived and designed this study ab and at conducted the data collection all authors contributed to the analysis and interpretation of data at wrote this manuscript with all coauthors commenting on the drafts of the paper all authors gave their approval for the final version to be published conflicts of interest none declared abbreviations

background increased access to the internet has facilitated widespread availability of health information thus electronic health ehealth literacythe ability to seek find understand and appraise health information from electronic resources and apply that knowledge in making a healthrelated decisionis a crucial skill despite the increasing use of the internet as a source of health information in developing countries only a few studies have examined the ehealth literacy of young adults who frequently use the internet to access health information in these developing countriesthe aim of this study was to assess the patterns of internet use and ehealth literacy levels among university students pursuing a nonhealthrelated degree in pakistan we also examined the association of the ehealth literacy levels of these young adults with their physical activity levels and dietary supplement intake methods students from 2 leading engineering universities in pakistan were invited to participate in a crosssectional anonymous webbased survey in order to collect data on their internet use ehealth literacy and dietary supplement intake of the 900 eligible university students who were invited to participate 505 561 students who completed the questionnaire were included in the analysis the findings were converted to median values and frequency analyses were performed the associations between the variables were determined using the chisquare test p≤05 was considered significantin this study the median ehealth literacy scale eheals score was 29 which did not vary across gender the most common type of healthrelated information that was searched by the participants was that related to maintaining a healthy lifestyle 305505 604 participants with high eheals scores were those who used the internet frequently for finding people with similar health issues p 001 the use of specific social media platforms was not associated with the perceived ehealth literacy levels neither the frequency of physical activity nor the dietary supplement use was associated with the ehealth literacy of the participants conclusions university students in nonhealthrelated disciplines in pakistan expressed high confidence in their skills to find healthrelated information on the internet as indicated by the aggregate eheals scores however the findings of our study show that the perceived ehealth literacy was not associated with health behaviors such as physical activity and dietary supplement intake further research is necessary to investigate the extent to which ehealth literacy can be considered as a panacea for solving public health challenges in developing countries

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background parenting has been shown to play a part in determining future mental health health related lifestyles injury rates 8 aspects of physical health 3 9 10 11 12 social competence 1314 and educational achievement 1516 suboptimal parenting is therefore a risk factor for a wide range of health outcomes and improvements in parenting could contribute to the achievement of a range of current policy goals through its impact on educational achievement and social competence parenting is also a determinant of future employability and thus of social inequalities in future generations parenting is by no means the only influence on these outcomes both the childs temperament 17 and their genetic makeup play a part together with environmental and social factors however there is some evidence to suggest that children with problem temperaments are particularly susceptible to suboptimal parenting 18 and that parenting also interacts with genetic risk 19 so even in families with the other risk factors parenting support may be a useful intervention parenting is amenable to intervention through group parenting programmes and the evidence base showing that such programmes are cost effective in treating conduct disorder and child behaviour problems is strong 2021 there is good evidence that they are also effective in preventing behavioural problems in highrisk groups identified by socioeconomic deprivation ethnic group and experience of life events 22 23 24 25 most of the evidence base on parenting programmes in the early years relates to two programmes the incredible years programme 2627 developed in the usa and triple p 2829 developed in australia both of which are now available in the uk both focus on the prevention and treatment of conduct disorder crime and delinquency 2529 through a targeted approach parenting interventions can be provided on a universal targeted or indicated basis the latter approaches have the strongest evidence base and lowest initial cost 20 21 22 23 24 25 however strong arguments can be advanced to suggest that universal provision increases the likelihood of change in high risk as well as whole population groups 30 31 32 given the range and ubiquity of health and social outcomes on which parentchild relationships have an influence 23 5 6 7 8 9 10 11 12 13 14 15 16 the inefficiency of targeting on the basis of identifiable risk factors 3031 and the prevalence of suboptimal parenting 33 universal approaches are appealing as a result most current government policies relating to parenting in the uk recognise the need for a universal component 3435 ranging from provision of information and support to universal access to parenting programmes 36 until recently very little rigorous evaluation of effectiveness has been conducted on parenting programmes in the uk but there has been a significant level of programme development several uk developed programmes including the family links parenting programme 37 are now widely available these programmes have much in common with iy and tp but focus more on the quality of the parentchild relationship and the parents wellbeing the flnp is popular with practitioners who see it as having a distinct contribution to make to promotion of health and wellbeing the current evidence base for this programme includes qualitative research showing that parents recruited through schools value the programme and perceive it to have an impact on family relationships childrens behaviour and their own mental health 38 before and after studies in community groups showing impact on self report measures of relationship quality and wellbeing 39 and routine evaluation by parents attending programmes showing that the great majority value the programme 40 none of this evidence allows an estimation to be made of the extent of programme impact relative to changes occurring in a control group or enables economic modelling of the costs and effects necessary to assess the relative value of expenditure on such programmes such evidence is essential to inform decision making on the best approach to provision of support for parenting lack of an rct evidence base makes commissioners reluctant to fund provision of the flnp and because of concern that the programme might no longer be provided in early years settings in their localities practitioners and commissioners in four counties in south wales and the welsh assembly government identified funding to commission an rct of the programme as a result of this commissioning process which included national open competition and external transparent peer review the trial has been adopted as a clinical research collaboration cymru portfolio study this trial aims 1 to measure the effectiveness of the family links nurturing programme in securing beneficial impact on parenting and health and social outcomes for young children and their families in the short and medium term 2 to measure the cost consequences of the flnp 3 to investigate the fidelity of programme implementation and delivery by practitioners in the trial sites 4 to investigate the views of families receiving the flnp in the trial sites related to perceived value attributed to the programme methodsdesign the study design is a multicentre investigator blind randomised controlled trial a setting the sample is being recruited from families of children aged 24 years in deprived areas of cardiff newport torfaen and caerphilly in south wales the sampling approach provides a geographical spread and coverage of different cultural groups and should recruit families representative of the uk population in relatively deprived areas the group for whom universal programme implementation is most clearly recommended and most likely to prove cost effective b sample size calculation we aimed to recruit 144 families into each of the control and intervention groups this sample size will be sufficient to detect an effect size of 04 at 85 power and alpha of 005 in the primary outcome measure an effect size of 04 is the level of difference which could be expected on the basis of changes observed on objective measures of parenting in recent uk trials of the iys programme 2541 in the majority of trials included in systematic reviews 2122 and in a before and after study of flnp 40 using self report measures the control families are offered flnp after data collection at six months post intervention is complete since the intervention is offered to groups a cluster design effect is included in the analysis such design effects are typically small in parenting programme trials one recent study of the iys programme in which both randomisation and intervention were subject to design effects identified intraclass correlations attributable to group effects ranging from 0 to 016 25 in our study potential design effects would be attributable to the groupbased nature of the intervention only as randomisation is being undertaken at the level of individual families if the intraclass correlation in our trial is as high as 0178 a sample of 288 will be sufficient to detect an effect size of 06 families who do not attend or dropout will be followed up alongside other families we anticipate a 20 loss to followup at 6 months postintervention based on the results of other trials 42 c recruitment consecutive parents visiting early years centres are being approached by practitioners those who agree meet with researchers either in the early years centre or on a home visit to discuss the research and to assess eligibility a repeat visit is made to those still interested 12 weeks later for consent collection of baseline data and randomisation to allocate families to control or intervention groups in families with more than one parentparent figure present in the household both parents are being invited to attend the groups but data are being collected only from the identified main carer families were offered a £20 voucher for each tranche of data in families with more than one child in the age range data are being collected for both children lack of independence of data from multiple children in one family will be taken into account in the analysis d intervention the flnp is a ten week programme involving 2 hour sessions each week for groups of 610 parents the programme is structured and aims to provide experiential learning through the use of guided discussion role play and home work parents set targets for themselves each week and report back on progress the following week the course covers a wide range of behaviours and attitudes which parents may or may not choose to adopt the ethos of the programme is that to empower parents to bring about changes in family life it is important to invite them to test different approaches and see which they can make work in their families rather than providing prescriptive instructions the four building blocks of the programme are the development of selfawareness and selfesteem appropriate expectations positive discipline and empathy the programme is eclectic drawing on social learning theory and psychotherapeutic insights it is founded on the belief that empathetic insight into emotional determinants of behaviour is important for both positive relationships and behaviour management it aims to provide parents with insights into the origins of selfesteem and positive relationships by drawing on their own experiences as children the programme thus supports parents in improving their own relationships with others as well as with their children parents are given a copy of the programme book the parenting puzzle 37 and each programme is run by two trained facilitators who receive face to face supervision three times during the course of the programme from an experienced programme facilitator the capacity to make compassionate relationships with the parents in the groups to empower and to support them and at the same time provide a tightly run structured group programme is seen as essential to success 2643 e outcome measures parenting programmes can affect family life and wellbeing in a variety of ways and families may respond differently no single outcome measure can capture all possible impacts our primary outcome measure is a composite index derived from observations made and questions administered during a home visit and recorded according to the home inventory 44 and responses to a parent report measure of parent child relations unpublished data collected at the same visit this measure is based on an index developed for the recent 3 year evaluation of sure start 45 in the uk which has provided data that are normally distributed and sensitive to change to supplement this primary outcome we have included objective measures of parenting a 10 minute video of a mealtime coded according to the mellow parenting scheme 46 this provides scores on six dimensions of parenting anticipation of childs needs responsiveness autonomy cooperation child distress and control conflict and a five minute speech sample capturing the parents description of their children and their relationship with each child we have included a range of validated and well used secondary outcome measures to capture health and wellbeing in parents and children for child wellbeing we have included pedsql parent report 47 and the preparent account of child symptoms 48 a standardised interview covering attentiveness antisocial behaviour and emotional problems together with mothers rating of the scale of the problem and her capacity to cope parental wellbeing is assessed using wemwbs 49 a 14 item self report measure of positive mental health and wellbeing parenting stress index 50 and a self report quality of life measure sf6d 51 the pedsql scale will be used as a parent proxy report of the health related quality of life of their child in order to produce utility estimates for the children in each arm of the study 47 the objective measures of parenting are collected during a home visit to the families in the two months before the programme starts and again six months post programme selfcompletion questionnaires are collected pre intervention immediately post intervention and six months post programme videos of parenting and five minute speech samples are coded up by researchers who do not know the families and all data analyses will be carried out blind to group allocation cost consequences are being established using health social service educational psychology or criminal justice service contacts for children and parents and use of voluntary sector services parental expenditure and time away from work attributable to these events or to involvement in the flnp unit costs will be attached using routine data sources 52 the cost consequences analysis will provide a clear descriptive summary of the results for each of the outcome measures set against the cost of flnp the views and perceptions of families receiving the programme are being assessed by interviews with 12 parents who decline to take part in the research study to determine possible ways of improving recruitment and 12 intervention group parents representing different cultural and social backgrounds and different experiences within the group to gather information on the most and least valued aspects of programme rating of the facilitators and ways of improving the programme programme fidelity is being assessed using video recordings of three random sessions in each programme coded by family links staff in addition both the parent and facilitator evaluation forms for the recorded sessions will be reviewed by family links uptake rates attendance rates dropout rates motherfather ratio of attendees and attendance and dropout by day and time of group are also being measured f analysis the primary statistical analysis aims to measure effectiveness in a pragmatic real life context this will be an analysis by allocated treatment using mixed univariate and multivariate analysis of variance taking into account level of attendance programme fidelity and differences in the characteristics of the two groups as measured by collection of data from parents at baseline parental age marital status housing tenure income ethnicity parental health and recent stressful life events as a supplementary analysis the potential of the programme to enable parents to change will be assessed in a regression analysis based on numbers of sessions attended secondary analyses will be undertaken of all other outcome measures adopting first an allocated treatment approach using mixed univariate and multivariate methods as above followed by an efficacy analysis intra class correlations will be assessed for all the main outcome measures and multilevel modelling used to take into account any design effects as well as the non independence of data from multiple children in one family a cost consequences analysis which allows an array of outcome measures to be considered alongside the cost of the programme will be undertaken to compare flnp with no intervention in parents and children from public purse societal and parents perspectives modelling will examine the sensitivity of the results to a range of assumptions video recordings of sessions will be analysed using an agreed structured coding framework to assess the extent to which facilitators achieved programme fidelity and the skills of the facilitator with a simple 15 fidelity rating applied to each programme for the qualitative interviews an iterative thematic analysis will be undertaken using data from all sources independently and results triangulated across these to identify areas of commonality and difference g ethics ethical approval for the overall study was granted by the north west wales research ethics committee on 6 th october 2008 after the parent information leaflet and consent form were translated into welsh no other issues were raised by the committee after piloting the outcome measures we adapted the measures to those outlined above and sought approval for these measures approval of this substantial amendment was given by the same research ethics committee on 22nd december 2008 h trial steering group an independent trial steering committee was established to monitor the progress of the trial including independent statisticians and trialists a child psychiatrist am educational psychologist and two layparent members and advise on modifications to the protocol as and when necessary in this section of the paper we report on the implementation of the trial in south wales including recruitment and follow up against our targets barriers identified during this process and adaptations made by the research team in order to address these challenges and other issues encountered in relation to the trial protocol implementation i recruitment against targets the original aim was to recruit 288 families to the trial at three sites in two phases running in september 2008 and january 2009 as the flnp runs during a school term however contractual processes delayed the appointment of research officers until december 2008 and only 25 families joined the trial for the january 2009 courses with more recruitment time the addition of another trial site and additional support from the primary care research network at clinical research collaboration cymru recruitment improved to 87 families by the end of phase 2 on the advice of the trial steering committee third fourth and fifth recruitment phases have been agreed to meet the trial sample size and trial funding extended accordingly the trial protocol included an option to recruit from general practice if centre based recruitment proved too slow ethical approval was gained for this eventuality in the original ethics submission during the fourth and fifth phase of recruitment an attempt was made to invoke this approach this had to be aborted because research governance approval to extend the trial into general practice took eight months to arrive j recruitment processes in each area there were some operational differences in the recruitment process across the four sites participating in the trial but the process is broadly as follows a programme coordinator or administrator received a referral form or informal information about families interested in the family links nurturing programme these referral forms come from a number of sources for example health visitors social services and childcare practitioners each referral to the study is assessed using the trial eligibility form those eligible to take part are given information about the research and asked if they agree to the researcher contacting them to discuss the trial the researcher organises a home visit to those families who agree explains about the research and gives an information sheet those families who agree to take part have a second visit from the researcher to complete the baseline outcome measures figure 1 describes flow of participants through the trial k adjustments made to initial planned methods of recruitment recruitment processes have changed over time as experience and new ideas were shared across the four sites the more effective recruitment methods are 1 developing and distributing more promotional material 2 building up relationships with practitioners at childcare settings and promoting courses beforeduringafter crèche 3 developing a newsletter for practitioners 4 attending groups where parents were already involved in centrebased activities 5 attending events such as play days etc which children between the ages of 2 and 4 and their parents attend throughout recruitment each area presented its own challenges but some of the barriers were common to all areas the main problems and solutions where achieved are outlined below referred by practitioners as potentially eligible n enrolment referrals a major barrier was professional anxiety about families entering the control arm of the trial and concern about the welfare of the family while they waited for the program it was important that the practitioners providing referrals fully understood the rationale for the trial and its ethical approval however a number of problems emerged at the referrals stage 1 delays in referrals with no understanding of the limited recruitment window for each phase of the trial 2 incomplete information on referrals 3 inappropriate referrals eg parents ineligible for the research with children too old or young or because a court order required a parenting course attendance 4 reluctance on the part of practitioners to promote the programme 5 professionals transmitting their own concerns over the research to potential participants eg by assuming the video element would cause anxiety 6 difficult relationships between professionals and potential participants it proved necessary to brief practitioners on more than one occasion and for the trial steering committee and chief investigator to send letters to managers outlining the consequences of failing to recruit on more than one occasion these issues were tackled by reeducating practitioners about the nature of the research and in caerphilly recruitment was opened up to a valley outside the flying start area in an effort to gain more referrals turning referrals into participants the participants often belong to hard to reach groups with a high level of literacy problems which prevents the widespread use of written material poor attendance at meetings and difficulties in establishing and maintaining contact with potential participants by phone or at the given address some potential participants could not be recruited because they set conditions on attendance examples included only wanting to take part in the course with a friend or relative unwilling to do it alone wanting to do the programme straight away and so being unwilling to risk allocation to the control group mistrust was another factor families presumed that people will judge the way they parent and became defensive some participants were concerned about data collection this generally centred on the filming worries included being judged on cleanliness or tidiness of their home concern that a dietician would look at what the children were eating and anxiety that social services or some other organisation would see the videos other families said that they could not be filmed because of religious or cultural issues in order to maintain high recruitment rates it was necessary to make the video optional although time consuming visits in person were more effective than phone calls or letters in some areas and tea and toast appeared to improve attendance at coffee mornings however heavy snow fall in early 2009 prevented visiting at a key recruitment time and in some instances group approaches proved counterproductive for example a dominant parent who did not like the sound of the trial was able to turn off an entire group who might have had a different response if approached individually conducting baseline visits contacting people for baseline visits also raised many of the above issues in addition some participants raised concerns that the information may impact on their receipt of benefits payments fidelity filming there was some facilitator anxiety about the video recording of flnp sessions to establish programme fidelity these facilitators felt they might be being judged and would not facilitate any groups involved in the research other facilitators would not promote the trial to ensure the group they were running was not evaluated follow up rates at date table 2 shows follow up rates immediately post intervention and table 3 shows follow up rates 6 months post intervention reasons for loss to follow up follow up rates have generally been high and have exceeded those expected however some families have been lost to follow up due to the following factors •some parents no longer feel the research is important at follow up •a prolonged postal strike in autumn 2009 resulted in delayed or lost immediate post intervention questionnaire many parents stated that they either did not receive the questionnaires or that they had already sent them back even though they were not received by the researchers •changes in address andor phone numbers without informing anyone connected to the study •changes in family dynamicssituations particularly families involved with social services meaning that follow up is no longer possible the researchers have attempted to overcome these difficulties by resorting to home visiting to collect the questionnaires and offering to help complete them when literacy problems were acting as a deterrent trial protocol implementation challenges to researchers remaining blind to allocation every care is being taken to ensure that researchers do not come into contact with trial participants allocated to the intervention arm when they gather recordings for fidelity coding and this strategy has been successful however whilst participants are clearly asked not to let the researcher know which groups they are in some do give away whether they had been on the course or not when visited for followup visits those who have been on the course and had enjoyed it may be enthusiastic to let the researcher know about the experience and those on the waiting list may ask how much longer they would have to wait for the course discussion randomised controlled trials of complex interventions are challenging to carry out for a number of reasons most obviously participants cannot be blind to intervention and it can be difficult as in this case to maintain complete blinding of the research team even highly professional researchers can be affected by knowledge of which group participants are in and the potential for bias will need to be considered in interpreting results objective outcomes which can be coded blind to group allocation are important in this respect however in this study these have not proved unproblematic with some parents refusing to be videoed with their child at a meal time for fear that this might be used as evidence against them by for example social services interventions such as parenting programs are most likely to be made available free of charge to families living in deprived circumstances but such families are often suspicious of authority in one form or another and may not value research in this same way as other families recruiting and retaining such families presents particular challenges we adopted a strategy of giving parents a gift for each tranche of data they provided and believe this has increased retention researchers have acted with great sensitivity and respect towards families and parents and many have said that they value the researcher visits so far our follow up rates have remained remarkably good given the challenging circumstances we were not anticipating that practitioners might also present a barrier to recruitment as this trial was funded by the county councils because of practitioner concerns that without an evidence base the programme might no longer be funded and because managers and practitioners attending a practitioners group for the trial were enthusiastic and very keen to make it work we believed initially that practitioners would all be supportive this turned out not to be the case research staff had to undertake many further discussions with practitioners in groups or on a one to one basis to explain the need for randomisation and convince them that it was in their interests and those of the families to support recruitment to the trial the existence of a practitioner group bringing together practitioners and managers across the four areas has enabled the practitioners and researchers to learn from each others ideas and overcome many of these obstacles to recruitment with five phases we have almost recruited to the sample size estimation of 288 but this has taken a year longer than originally planned the support of the trial steering committee was important in persuading the county councils that the research team were doing all that could be done to achieve the necessary level of recruitment and that additional funding was required to extend the recruitment period the group based nature of this programme and the fact that programmes can be run only three times a year in term time also presents challenges for recruitment unless a parent has been to the first session they cannot join a group although they can of course drop out recruiting too early may mean that families lose interest by the time the programme starts this has meant that there are only three windows for recruitment each year in the first year one of these windows corresponded to a time in which there was an extremely heavy snow fall and the valleys of south wales were not easily accessible when we designed the trial we assumed that each parenting programme would be filled with trial participants however because of challenges to recruitment and because groups are not viable with less than six parents many of the trial parenting groups included families who were not part of the trial we failed to anticipate this and as a result we have had to film and will need to code many more sessions than we originally expected a further challenge to studies of interventions which often involve complex changes in behaviour or family relationships is to choose an appropriate outcome measure well validated measures are essential for the credibility of the results yet such measures may not capture all possible changes that may occur for this reason we have opted to collect multiple outcome measures both self report and objective but this has increased respondent burden and also researcher time and therefore the cost of the trial the primary outcome is a composite measure which has worked well in other studies we have examined the properties of this measure in the baseline data to ensure that it is statistically sound in the current study and presented the findings to the trial steering committee for confirmation of the primary outcome before completion of data collection gathering video data is valuable in providing objective evidence in this trial it proved challenging for some parents who found it difficult to trust the research team to maintain confidentiality it also proved challenging to facilitators who needed to be videoed for fidelity coding it is easy to underestimate how nervous skilled group facilitators may be in the face of possible when a judgement of their skills hutchings et al reflect on lessons learnt from running three pragmatic randomised controlled trials of child mental health interventions in wales 53 six themes emerge 1 identification of suitable partner services for trials 2 early recruitment of service managers in study planning and ongoing shared management 3 clarification of contributionsrequirements from all partners 4 ethical and sensitive recruitment of participants 5 building an understanding of research evaluation 6 enhancing the fidelity of the programme 53 we concur with these insights this has been an extremely challenging trial to run it could have failed at several points but is now on course to succeed the key to success has been an absolutely committed very hard working team of researchers and experienced academics across two universities an absolutely committed supportive group of early years commissioners and managers in south wales and the hard work of a great many practitioners working on the ground to recruit families abbreviations competing interests the authors declare that they have no competing interests authors contributions ds helped to conceive and design the study and drafted the manuscript hs helped to conceive and design the study and critically revised the manuscript for intellectual content ns participated in the design of the study and will perform the statistical analysis sd helped to design the study and performed the economic analyses mt ba sw and lw contributed to the implementation and discussion sections of the manuscript ssb conceived of the study and participated in its design and coordination and helped to draft the manuscript all authors have read and approved the final manuscript

background suboptimal parenting is a common risk factor for a wide range of negative health social and educational outcomes most parenting programmes have been developed in the usa in the context of delinquency prevention for targeted or indicated groups and the main theoretical underpinning for these programmes is behaviour management the family links nurturing programme flnp focuses on family relationships as well as behaviour management and is offered on a universal basis as a result it may be better placed to improve health and educational outcomes developed in the uk voluntary sector flnp is popular with practitioners has impressed policy makers throughout the uk has been found to be effective in beforeafter and qualitative studies but lacks a randomised controlled trial rct evidence base methodsdesign a multicentre investigator blind randomised controlled trial of the flnp with a target sample of 288 south wales families who have a child aged 24 yrs living in or near to flying startsure start areas changes in parenting parent child relations and parent and child wellbeing are assessed with validated measures immediately and at 6 months post intervention economic components include cost consequences and cost utility analyses based on parental ranking of states of quality of life attendance and completion rates and fidelity to the flnp course delivery are assessed a nested qualitative study will assess reasons for participation and nonparticipation and the perceived value of the programme to families by the end of may 2010 287 families have been recruited into the trial across four areas of south wales recruitment has not met the planned timescales with barriers including professional anxiety about families entering the control arm of the trial family concern about video and audio recording programme facilitator concern about the recording of flnp sessions for fidelity purposes and delays due to the new uk research governance procedures discussion whilst there are strong theoretical arguments to support universal provision of parenting programmes few universal programmes have been subjected to randomised controlled trials in this paper we describe a rct protocol with quantitative and qualitative outcome measures and an economic evaluation designed to provide clear evidence with regard to effectiveness and costs we describe challenges implementing the protocol and how we are addressing these

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introduction the concept of crisis encompasses a wide range of phenomena that profoundly impact individuals and society this analysis delves into crises underlying causes and complex nature highlighting the subjective reactions they provoke as the defining essence crises can originate from many factors including intrapsychic relational and environmental elements pervasively affecting individuals throughout their lives in todays interconnected world the media is pivotal in exacerbating global crises amplifying uncertainties and threatening overall wellbeing consequently crises have become a pervasive aspect of modern life leading to stress and significant physiological changes in individuals this examination emphasizes the broad and varied definitions of crises characterized by the occurrence of specific situations or events and the subsequent subjective responses the personal reaction encompasses cognitive and affective aspects serving as the foundation for following behavioural patterns typically individuals perceive crises as challenges to their values threats or losses necessitating a shift in their perception of the situation eliminating irrational thoughts and searching for meaning furthermore this analysis explores the multidimensional nature of crises across diverse domains including medicine personal and social life politics and the economy sociologists perceive crises as tensions and social conflicts with profound consequences for community development while doctors view them as disease breakthroughs followed by symptom resolution economically crises entail the collapse of development and regression in the psychological realm crises are acute disturbances of mental balance triggered by highly challenging situations effective coping strategies are paramount in managing crises three primary stress management styles are discussed taskoriented emotionally focused and avoidancebased selfefficacy plays a crucial role in crisis intervention representing an individuals belief in their ability to organize and implement actions necessary for overcoming obstacles social support selfesteem and positive attitudes towards others are vital in successfully navigating crisis situations this analysis sheds light on the intricate nature of crises their diverse origins and the subjective reactions they elicit it emphasizes developing adaptive coping strategies cultivating selfefficacy and fostering social support networks to navigate and transcend crises effectively understanding the multidimensional aspects of problems and employing resilient responses is crucial for individuals to thrive in adversity the crisis is an unusual phenomenon in terms of aetiology and distinctive image on its basis many intrapsychic relational and environmental factors were created while its effectiveness applies to all criteria of the subjects functioning in the current crisis world we introduce stress from birth to death with them and make changes in the body the media threaten the global crisis which affects the psyche of the recipients increasing their uncertainty of tomorrow it conflicts with nature and everyones need for wellbeing the crisis is therefore a broad and variously defined concept most definitions contain at least two common elements the first is the occurrence of a specific situation or event the second emphasized by most researchers is the emergence of a subjective reaction which is the essence of the crisis not the situation or event itself the personal response is expressed in the subjects specific perception of the situation and emotional reaction which are the basis for further behaviour the cognitive model emphasizes that in a crisis a person usually perceives events in terms of violation of his values threat loss or a combination of these beliefs and regaining control over his life is the result of changing the way of assessing the situation getting rid of irrational and destructive thoughts and searching for the essence of events concept of crisis functions the concept of crisis functions in many areas of life in medicine in personal and social life in politics and economy there can be infinite reasons for it both on the global level eg war global crises global warming pandemics or on the personal level eg illness separation death loss of sense of security due to loss of job from the point of view of etymology the crisis has not only a pejorative meaning but is a much richer concept a crisis is essential to a gradually growing threat situation resulting from new or surprising circumstances it is associated with a real or perceived loss of control over a situation or problem it is generally associated with a lack of conception of solving a crisis thus causing severe stress colloquially a crisis means personal difficulties problems or sudden obstacles in life from the point of view of the companys policy the situation concerns the collapse of existing concepts the continuity of governance or the temporary loss of the companys controllability the crisis can therefore be perceived from different perspectives for sociologists a crisis is an accumulation of tensions and social conflicts with specific consequences for community development doctors see it as a state of breakthrough of the disease after which its symptoms disappear quickly in economics it means the collapse of economic development and regression psychological crisis also called emotional in the socalled in the classic sense it means acute disturbances of mental balance caused by a confrontation with a situation subjectively assessed by a person as extremely difficult stress increases when there is a need to face difficult experiences therefore each crisis intervention refers more or less directly to a broadly understood emotional crisis specialists focused on fighting stress and situations crisis specialists try to develop in their patients various coping mechanisms for difficult situations stress emergency and critical and traumatic events a man aware of how his brain works under stress can learn to use it wisely during extreme stress the typical human reaction to a crisis consists of three stages denial assessment of the situation and decision the denial mechanism is usually the first reaction to stress followed by assessing the situation at this stage the more time you have the easier it is to react to stress and see it in a broader context allowing you to consider many options for action or tame emotions the type of decision taken is conditioned primarily by the individuals mental toughness and the ability to use previously developed strategic scenarios of conduct coping with stress styles selfefficacy and internal conflicts in crises in todays world the quality of functioning largely depends on developing an appropriate coping style in the literature on the subject there is information about three coping styles the first is the taskoriented style which means taking purposeful actions this style is chosen by those for whom the most important thing is to solve a problem or change an existing stressful situation by using cognitive processes the emotionally focused style is generally chosen by people with wishful thinking who fantasize at the expense of rational action in their opinion removing or minimizing the stress stimulus is not important reducing the emotional tension accompanying the stressful situation is more important so they need to take real action to solve the stressful problem and therefore it is difficult for them to achieve a positive effect which often ends with increased mental tension another style of action is the style focused on avoidance this attitude is associated with rejecting thoughts about the fundamental problem preventing one from experiencing it and getting involved in solving a stressful situation which often means an inevitable escape from the problem these styles do not always occur in a pure form sometimes they penetrate each other success in the fight against the crisis may be determined by internal selfefficacy which means faith in ones ability to organize and implement the actions needed to overcome obstacles it allows for a specific assessment of ones competencies making coping with various challenging tasks easier this individual judgment determines the perception of ones situation thinking and emotions which affects motivation and behaviour the effort put into achieving the goal and the belief in ones effectiveness are very important for the actions taken faith largely determines how people think feel motivate and behave influences choices perseverance in action or effort put into achieving a goal selfefficacy is the foundation of motivation it is sometimes much more critical for a persons actions than the objectively encountered reality when people believe they can handle the situation they find themselves in they become creative and resilient to adversity in a crisis a person generally sees one major conflict only in the course of realizing the situation and searching for its sense is it possible to reveal several conflicts which trigger the internal mechanisms of coping with the situation first there is the destruction of established beliefs and ideas about the regularities of the world and the consequences of ones actions in it a critical situation undermines or destroys the values or subjectively significant assumptions of the worldview developed during an individuals life thus a person experiences a feeling of surprise horror and the situations absurdity in this case in the coping process the person is tasked with evaluating the value of his worldview assumptions the way to deal with a crisis is related to cognitive decentration viewing reality from a nonegocentric perspective and building a different life perspective based on facts that can no longer be changed the image of ones future fulfils a regulatory function in behaving in a planned manner and temporal identity is the basis for individual coherence an uncertain prospect of the future or the expectation of a negative effect evokes fear and anxiety the problem arises on its own or accompanies other conflicts in the situation a person does not have an assured future and does not see a further life perspective the way to deal with a given internal conflict is consistent with finding valid criteria for making a significant choice of life alternatives and drawing a picture of the individuals possible future in as much detail as possible another difficulty is the problem of damaging selfesteem by being underestimated by other people in this case the internal conflict of a critical situation means above all not that the person experiences a sense of injustice but that subjectivity and appreciation of his personality are denied it is a situation in which a person has the impression that life treats him like an object the way to solve such problems is to isolate yourself and the nagging factor rebuild subjectivity prove your worth and accept the right aspects of the situation another internal conflict in a critical situation is the conflict between the real selfself and the ideal selfself this conflict is least pronounced from the outside and depends on the level of selfawareness it causes a sense of shame but leaves the clerk the most freedom the way to deal with it is to integrate and harmonize the content of your selfself which is carried out by establishing a hierarchy of values psychophysical features genetically assigned to each individual and personality determine its functioning in a crisis situation they can sometimes play a greater role in a stressful event than the circumstances of the event itself resilience is an essential trait a person endowed with it believes that he impacts his own life he can always find a goal and persistently strive to achieve it he can conclude all experiences positive and negative this makes it easier to control the crisis and more effectively react to stressful situations many interpersonal conflicts causing stress or crisis result from unkindness or intolerance full of criticism towards others we are prone to making hasty opinions and severe judgments that cannot be undone and corrected we dont always show understanding and patience with others although we expect it from others the group bond gives a sense of security providing psychological support that even the best therapist will never show summary and conclusions to successfully survive in a crisis it is necessary to develop the ability to cope with difficult situations independence in solving complex life problems and overcoming all kinds of difficulties man is a social being one of his most essential needs is contact communing with another person and the need to understand and be understood the quality of life depends on whether this need for communication is met selfesteem is essential but only when combined with a positive attitude towards others the process of socialization equips an individual with the ability to be a member of particular social groups and contributes to shaping his personality while making his social participation more conscious adaptation to social rules is accompanied by increased motivation for social activity and orientation towards selfrealization and consequently improvement of ones image unfortunately we live in times of uncertainty terrorist attacks floods and even everyday life are an opportunity to train behaviour in the face of danger every person who has experienced a crisis can survive only when they take full responsibility for their lives and the events

crises can originate from many factors including intrapsychic relational and environmental elements pervasively affecting individuals throughout their lives the paper focuses on the intricate nature of crises their diverse origins and the subjective reactions they elicit it emphasizes developing adaptive coping strategies cultivating selfefficacy and fostering social support networks to navigate and transcend crises effectively understanding the multidimensional aspects of emergencies and employing resilient responses is crucial for individuals to thrive in adversity

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introduction covid19 caused by sarscov2 virus is one of the most significant pandemics the world has seen in recent decades 1 it has led to unprecedented challenges in all sectorshealth social and economic and has called for coordinated efforts globally and locally for its mitigation 2 we are currently in the second year of the pandemic leading to millions of cases and deaths worldwide 3 low and middleincome countries have borne the brunt of the pandemic in comparison to other developed nations given their already overburdened health systems prior to the pandemic and unique challenges of limited resources and poor infrastructure lack of access to reliable information for households in resourcepoor settings and competing health priorities 45 in addition lmics face more challenges in rolling out nonpharmaceutical interventions like lockdowns as their associated outcomes such as loss of employment income or disruption of food or water would affect peoples ability to adhere to lockdown conditions and also their health and wellbeing 6 in india the first case was detected on 27 th january 2020 7 during the first wave a prompt nationwide lockdown was imposed in march 2020 which helped in containing the pandemic the subsequent easing of restrictions and resumption of economic activities in an uncoordinated manner resulted in a second wave of infections that stretched the countrys health system beyond capacity and saw a large number of deaths 8 this clearly highlights that a country like india which is the second most populous country in the world is densely populated and has a high internally mobile population 9 will always be at risk of multiple waves of infections and adverse impact till the pandemic is over earlier outbreaks like sars and ebola have highlighted the importance of risk communication and community engagement for health emergency readiness and response activities 10 timely and proactive communication on what is known what is unknown and what is being done to get more information plays an important role in gaining the trust of the communities 11 experiences from past infectious disease outbreaks have shown that they were accompanied with misinformation myths associated stigma etc which hindered the containment and mitigation measures taken by the authorities 12 during the ebola outbreak in nigeria and guinea the misconceptions regarding the disease led to lack of preventative behaviour as well as mistrust and attack on health care providers 13 similarly for covid19 there is a strong need to adopt a localespecific approach to create awareness among specific clusters of population regarding prevention spread and treatment of covid19 14 the world health organization lists risk communication and community engagement as an important measure to flatten the transmission curve and mitigate the impact of the covid19 pandemic 11 this can be done only if there is an understanding of the communitys readiness to adopt behaviour practices and measures suggested by health authorities 15 assessment of the knowledge attitude and practices of people towards covid19 will play an integral role in understanding and adopting specific approaches for controlling of spread of covid19 16 a particularly vulnerable group of population are those belonging to the lower socioeconomic strata depending on daily wages for survival and having limited access to internet media etc 1718 these populations are at greater risk of getting infected which is amplified by their lack of information and access to quality healthcare as well as their already compromised socioeconomic determinants 19 program the united states agency for international development s flagship health system strengthening project nishtha is working across 13 states in india and providing technical support to strengthen the governments response for covid19 nishtha is a hindi word meaning commitment signifying the projects commitment towards strengthening primary health care to support the above described vulnerable communities during covid19 and to ensure they have access to timely and correct information nishtha set up a communication platform to reach the target population through an alternate medium and link them for appropriate care through a network of local partners the risk communication platformnishthaswasthya vaani was rolled out in the month of august 2020 in four districts of madhya pradesh state and one district of jharkhand state the communication platform used an integrated voice response system it was developed by gram vaania social tech companyas an innovative social media platform for the noninternet users living in rural areas this platform was chosen for risk communication as the smart phone and internet penetration in these regions particularly in the rural areas is very low 20 however the mobile phone penetration is considerably higher with over threefourths of the population using mobile phones 20 a tollfree number was generated where community members could access information regarding covid19 through the ivrs information about the tollfree number and the nishthaswasthya vani platform was disseminated to the community through pamphlet distribution iec material display at prominent locations in the community and through active reach out by community volunteers and frontline workers particularly in rural areas this platform provided risk communication messages to the vulnerable populations including migrant workers and their families elderly persons with disabilities urban poor and other people living in remote areas the messages related to covidappropriate behaviours basic information on covid19 antistigma antidiscrimination and countering misinformation as an additional part of the intervention in order to further tailor the messages to the targeted population served by the project a survey was administered to understand the existing knowledge attitude and practices towards covid19 so that effective risk communication messages could be designed for addressing the knowledge attitude and practice gaps the primary objective of this survey was to know the knowledge attitudes and practices of poor and marginalized communities towards covid19 and determine the factors associated with it methodology study design this was a crosssectional study done using a structured questionnaire administered through an ivr system the survey was conducted using the same ivrs platform that was used to disseminate risk communication and awareness messages due to limitations of the ivrs platform a limited number of questions were incorporated into the survey instrument study site this study was part of the nishthaswasthya vaani program which was implemented in 4 districts of madhya pradesh and 1 district of jharkhand four out of these five districts are aspirational districts and have ongoing nishtha interventions aspirational districts are those identified districts by government of india that have shown relatively lesser progress in key social areas and have emerged as pockets of underdevelopment 21 in addition rural areas of these five districts have a very high incidence of poverty when compared with the national incidence 22 study population the study population included all the people living in the ranchi district of jharkhand and khandwa guna barwani and rajgarh district of madhya pradesh ranchi is the capital city of jharkhand with a population of more than 29 million which is 88 of the population on jharkhand and has a literacy rate of 76 23 khandwa rajgarh guna and barwani have a population of 02 million 15 million 12 million and 13 million respectively and literacy rates of 66 61 63 and 49 respectively 24 study participants people from all the five districts were informed about the platform by displaying the tollfree number in prominent areas such as health facilities chemists shops etc in addition a set of community volunteers as well as frontline health workers informed the people belonging to the above described vulnerable group about the platform and ivrs number through outreach activities in the rural areas people who were interested in listening to the messages called the ivrs number all the firsttime callers who accessed the nishthaswasthya vaani platform by diallingin the tollfree number in the first 3months since its launch were directed to the survey those who opted to participate and answered 4 or more questions were included in the study study duration this study was conducted in a time period of 3 months from august2020 to october 2020 study instrument the study tool was a structured questionnaire developed on the basis of literature review 25 26 27 28 29 existing guidelines given by who government of india and indian council of medical research and with inputs from field experts who have professional degrees in medicine and public health and have experience of working with the target population the questionnaire was also shared with government program managers of the states and respective districts for feedback before opening the survey for the community on the ivrs platform it was also reviewed by team gram vaani who are experts in utilizing ivr based platforms for conducting community surveys 30 to check for its appropriateness for the ivr platform the survey was administered in two partsa short questionnaire and a long questionnaire so that the loss of respondents over the course of the survey could be minimized the short questionnaire consisted of questions on sociodemographic details such as age gender district marital status occupation and education source of information and five questions assessing knowledge and attitudes the longquestionnaire consisted of nine questions further assessing the knowledge attitudes and practices the questions pertaining to knowledge asked about common symptoms mode of spread prevention steps to take and people at increased risk questions pertaining to attitude asked about concern regarding covid19 attitude towards social gathering as well as questions related to stigma towards patients and healthcare workers the practices section had questions regarding mask wearing and hand washing study procedure when the users dialled in the tollfree number they were first read out an automated introductory message and instructions for the survey everyone who accessed the platform was asked to answer questions on sociodemographic characteristics after which they were directed to the short questionnairewhich assessed the knowledge and attitude towards covid19 the questions and answer options were read out in the local languagehindi the respondents could choose their answer by dialling in the option number the questions were not mandatory and could be skipped in addition the users had the option of listening to the question again by dialling in a number post completion of the short questionnaire the users were given the option of proceeding to the long questionnaire or accessing the available content on platform those who proceeded to the long survey were asked additional questions on knowledge attitude and practices towards covid19 the respondents could not go back to the survey after accessing the content and on repeat calling to avoid duplication and bias statistical analysis the data were extracted from the ivr platform in comma separated values format and exported to spss statistics for windows version 170 for further analysis the sociodemographic characteristics and survey responses were recorded as frequencies and percentages the mean scores for the domains of knowledge attitude and practices was calculated after scoring the individual responses each knowledge response was scored as 1 for correct answer and 0 for incorrect answer the attitude responses were scores as 1 for desirable and 0 for undesirable the practice responses were scored as 0 for never 1 for occasionally and 2 for always the scoring for the domains ranged as follows 08 for knowledge 04 for attitude and 04 for practices additionally 2 of the attitude questions constituted the stigma score ranging from 02 we converted mean scores to percentages and used a cutoff of 80 for categorizing low and high scores as per blooms cutoff 31 the mean and standard deviation of the scores was calculated the mean scores were compared based on sociodemographic parameters using anova ftest although the distribution was nonnormal for some of the categories due to the fairly large sample size of the study in accordance with the central limit theorem and the robustness of the anova test we decided to consider the anova results and opted for the same 3233 while comparing the means using anova the homogeneity of variances was tested using levenes test for homogeneity and wherever the assumption of homogeneity of variance was violated we have presented the welch anova results the post hoc tests were applied wherever anovawelch anova was significant using tukey hsd test for anova and games howell test for welch anova correlation between knowledge attitude and practices score was assessed using pearsons correlation correlation of stigma score with knowledge was also done a correlation coefficient of upto 03 was regarded as weak correlation from 03 to 07 was regarded as moderate correlation and greater than 07 regarded as strong correlation 34 multivariable linear regression was run using enter method for the knowledge and attitude scores with independent variables age gender marital status education occupation and main source of information the models were run after testing for assumptions of linearity normality homoscedasticity and independence of observations in addition they were also assessed for multicollinearity and presence of outliers for the linear regression model on attitude the knowledge score was also included as an independent variable regression was not run for practice scores as the assumptions of linearity and normality were not met the significance level for all the tests was set at p 005 ethical considerations the institutional review board of the johns hopkins bloomberg school of public health usa determined the study as a public health surveillance activity requisite permissions for rolling out the platform in five districts were also obtained from the state governments of madhya pradesh and jharkhand considering the survey was administered using an ivrs platform it was not possible to obtain consent from individual participants however in accordance with the determination notice the participants were notified about the survey through an oral script that was played at the start of the survey explaining the purpose and procedure of the survey the participation in the survey was voluntary and all community members could access the information even if they did not wish to take part in the survey in india the legal age for acquiring a mobile phone number in india is 18 years and because the survey required voluntary participation by diallingin the ivr number it was considered that all participants below 18 yrs of age had parental or guardian consent for accessing a mobile phone and participation in survey results sociodemographic characteristics across 5 districts a total of 24483 calls were either made to or received from the nishthaswasthya vaani channel in the period between august to october 2020 these included 6672 firsttime callers to the tollfree number who were directed to the short survey of these 3396 individuals answered at least 1 question of the short survey and 1289 completed it who were then directed to the long survey of these 861 participated in the long survey and 577 completed it the mean duration of time spent by respondents on each of the two surveys was around 3 minutes for ensuring data quality as well as to minimize the number of no responses only those 1673 individuals who answered at least 4 out of 14 kap questions were included in the analysis the status of users of the platform and participants in each survey between august to october 2020 is shown in fig 1 among the respondents included in the analysis 667 belonged to the age group of 1635 years and 634 were male out of all the respondents 426 had an education from standard 6th to 12th while 171 of them had no formal education agriculture or daily wage labourers represented 321 respondents followed by farmers unmarried individuals constituted majority of the survey respondents detailed demographic characteristics are shown in table 1 source of information more than half of the respondents reported radio tv or newspaper as their main source of information on covid19 about 14 respondents reported that the local health workers or the local health facilities were their main source of information on covid19 assessment of knowledge only around onethird of participants were aware that fever and dry cough are symptoms of covid19 infection and more than threefourth of the participants knew that people with chronic diseases such as diabetes heart disease obesity are at higher risk when asked about steps one can take to prevent infection less than half selected the correct option of washing hands with soap and water frequently more than a quarter of the respondents believed that people with covid19 infection who do not have any symptoms cannot spread infection to others a large proportion of the participants were not aware about minimum physical distance of 2 meters to protect oneself from infection almost 53 respondents either thought that children and teenagers do not need to make efforts to prevent infection because they have a strong immune system or were not sure the responses for knowledge scores are as depicted in table 2 the mean knowledge score for participants was 406 assessment of attitude risk perception prevention intentions and thoughts regarding covid19 infected persons and care takers were analysed almost onethird of participants reported that they constantly worried about contracting covid19 infection when asked whether there is a chance of the infection spreading if a crowd happens for a religious purpose 307 were either not sure or thought there was no risk of spread in a religious gathering more than onethird of the participants agreed that for the safety of people patients who have recovered from covid19 should not be allowed to live in the area while 97 were not sure further 341 of the participants agreed that for the safety of people healthcare workers taking care of covid19 patients should not be allowed to visit their area while 58 were not sure the responses of participants for questions on attitude are as depicted in table 3 the mean attitude score of the participants was 246 assessment of practice more than 80 respondents reported that they always wear a mask whenever they were outside and washed hands with soap and water frequently whereas only 15 reported not following the preventative measures at all times the practices as reported by the respondents is as shown in table 4 the mean practice scores were reported to be 365 mean knowledge score differed significantly across district education occupation main source of information and education level as depicted in table 5 the knowledge scores were significantly higher for those who stated that their main source of information was radio tv or newspaper as compared to no source the knowledge attitude and practice scores were lower for farmers agriculture and daily wage labours as compared to salaried employees although there was no significant difference in practice scores across occupation groups the knowledge attitude and practice scores were significantly higher for those in the age group between 3655 and 16 to 35 than younger respondents the knowledge attitude and practice scores were significantly higher for those who had received higher education as compared to those who had lesser school education there was no significant difference between the knowledge attitude and practice scores of males and females correlation between knowledge attitude and practices assessment of correlation demonstrated that knowledge has a moderate positive correlation with attitude and a weak positive correlation with practices whereas attitude and practices were also weakly correlated as shown in table 6 additionally the knowledge score showed a negative correlation with stigma determinants of knowledge attitude and practice scores in regression analysis for knowledge and attitude scores the models for knowledge and attitude were significant with an r 2 value of 0027 0152 respectively age b 0 discussion the mean knowledge attitude and practice scores for participants were 406 246 and 365 respectively factors associated with the knowledge attitude and practice scores were education occupation age and primary source of information there was a positive correlation between knowledge and attitude whereas there was a negative correlation seen between knowledge and stigma on multivariable regression analysis age and primary source of information was a significant determinant of knowledge score while education and knowledge score were significant determinants of attitude score the covid19 pandemic continues to spread and has posed as a major public health challenge at global national and local levels although the vaccination drive is ongoing 35 it is important to ensure that people continue to adopt the preventive and promotive behaviours such as washing hands regularly social distancing and wearing a mask 36 for promoting preventative practices and attitude knowledge about disease and expected behaviour is very important 37 in the present study knowledge among the study participants was found to be poor with a mean score of 406 and 507 correct answer rates score of 80 and above determines sufficient knowledge a cutoff identified by olum et al 38 this finding is in contrast with other studies done in other parts of india asia and similar lmics that have shown satisfactory or good levels of knowledge this difference can be attributed to the fact that our study caters to the poor and marginalized communities of centralindia with low access to internet as compared to other studies which were primarily done among internet users of more accessible areas in our study a majority of people reported their main source of information to be radio tv and newspaper while the proportion of people relying on internet friends or relatives and local health facility was comparatively smaller it was also seen that the mean knowledge score was higher for those who relied on radio tv and newspaper than those who identified no primary source of information this highlights the need to promote and make accessible alternate information sources through these media platforms these findings are in accordance with a multinational study done by john hopkins center for communication programs that states that the exposure to information from radio tv newspaper and internet is not only higher in india but is also associated with more trust on the information source 39 therefore it is vital to tap into the potential of these communication platforms to disseminate the right information in a timely manner among the 8 questions knowledge about common symptoms of covid19 infection and washing hand frequently was relatively low at 353 and 403 respectively the results suggest strengthening of preventive approach through feasible and effective risk communication strategies it is also a matter of great concern that 53 of participants did not know that covid19 infection can be spread by asymptomatic person this lack of awareness may negatively influence the covid19 appropriate behaviours more than threefourth of study homogeneity assumption violated pvalue represents for welch anova there was no significant difference found on posthoc analysis � the practice scores of barwani was significantly greater than guna rajagarh and ranchi �� the knowledge scores was significantly higher for those who said the main source of information radio tv newspaper than those who claimed they did not have a source ��� the practice scores were higher for those who said their main source of information was local health workerfacility than those with friends or relatives as main source of information μ the knowledge attitude and practice scores were significantly lower for less than 16 than rest of age groups the knowledge scores were significantly higher in salaried employees than farmers the attitude scores were significantly higher in salaried employees than housewiveshousehusbands and farmers the practice scores were significantly higher in salaried employees than farmers and agricultural or daily wage labours ß the knowledge attitude and practice scores were higher in those with higher education than all of the groups participants were aware of the fact that people with comorbidities such as diabetes heart disease and obesity are at higher risk which is similar to the findings of a study conducted in maharashtra by shukla s et al 40 our study revealed that almost onethird of the participants reported worrying all the time about contracting covid19 according to a global survey done by yougov 41 indians are more fearful of covid19 compared to western countries but are less scared than other asian economies the finding of our study is similar to a study conducted by grover et al which found that more than onethird respondents reported fear and anxiety of acquiring covid19 infection 42 this might be because the survey was conducted after lockdown and people might have witnessed impact of lockdown on household income and social lifestyle or because of mysterious nature of the virus often fear results into stigma and discrimination a section of society is at higher risk of covid19 so the issue of stigma needs special emphasis when asked if patients who have recovered from covid19 should be allowed to enter their locality and if health care workers treating covid19 should be allowed to enter their locality over a third of the respondents replied in the negative this indicates a high prevalence of stigma among the participants this is similar to another study done among housekeeping and janitors where a similar apprehension was seen in inclusion of covid19 recovered patients in mainstream society 43 this study found negative correlation between knowledge and stigma which suggests that correct information is crucial for addressing stigma this is important from the public health standpoint because in the past we have witnessed fear and stigma undermining the public health efforts towards control and elimination of various diseases such as hivaids tuberculosis etc 44 it also has serious mental health implications on the recovered patients and health care workers 45 in a country like india where violence against healthcare workers was already prevalent and on the rise the stigma further fueled violence against doctors and health workers with many reports of discrimination and attacks on health workers by patient attendants communities and landlords 46 our study suggests that over 80 participants reported always wearing a mask whenever they went outside in the past few days and washing hands with soap and water frequently around 15 of the participants reported not following the practice of wearing mask and frequent hand washing regularly the findings are in contrast with the john hopkins survey where the practice was lower in rural areas 39 it should be noted that the studies have mostly reported selfreported practices and may not be reflective of the actual picture the kap scores are significantly higher in those with higher education those who were salaried employees over the agriculturaldaily wage labours and farmers also the middleaged and those between 1635yrs fared better in practice than younger respondents less than 16 years there was no difference between the kap scores of males and females these findings emphasize on the need to target risk communication messages to the vulnerable population and those with lack of access to reliable knowledge such as those with lower education farmers agriculturaldaily age laborers our study found moderate correlation between knowledge and attitude suggesting that higher knowledge will help in inculcating positive desirable attitudes towards covid19 this is in line with the findings from other studies 4748 our study findings are in contrast to other studies done using online survey methods where a higher kap score was depicted 4950 this could be attributed to the difference in the survey platforms and the communities involved online platforms have reflected higher kap due to higher reach and therefore higher awareness regarding covid19 this further reinforces the need to reach out to the populations with low internet usage through alternate channels however the practices reported were similar in the present study and these studies possibly because being selfreported information respondents reported a higher level of adherence to covid19 appropriate behaviours our study found age and source of information to be the main determinants of knowledge whereas education and knowledge scores were the significant determinants for higher attitude scores these determinants are similar to findings from other studies which have also stated education knowledge and source of information to be important determinants 5 strengths and limitations to the best of our knowledge this is the first survey assessing the knowledge attitude and practices related to covid 19 among poor and marginalized populations of the states of madhya pradesh and jharkhand who do not have a high degree of internet penetration the usage of the interactive voice response system for data collection facilitated inclusion of a large number of respondents which would not have been possible in a short time through housetohouse survey considering the restrictions which were in place at the time of survey the use of ivrs platform also facilitated reaching out to a category of participants who are usually missed out in internetbased surveys or studiesa lot of which were conducted to answer similar research questions during the same period the insights from this baseline assessment are being used to design effective risk communication messages and information regarding covid19 there are some limitations of the study due to limitations of the usage of ivrs platform there were missed responses for the questions secondly since the survey participation was respondentdriven there may have been a selection bias and hence findings may not be completely representative of the study population also since it was a selfreported survey there is a possibility that the responses towards attitude and practices may be influenced by social desirability bias and is not reflective of the actual scenario policy recommendations extensive risk communication needs to be done with relevant and updated information through alternate media channels such as local media platforms radio and newspapers which are accessed by the marginalized communities where internet penetration is not high targeted interventions need to be made for knowledge dissemination regarding covid19 among the vulnerable population as these populations are more at risk and less likely to be able to follow social distancing measures dispelling myths and tackling misinformation is important as correct information is directly correlated with more adherence to covidappropriate behaviour and lesser stigma conclusion the knowledge attitude and practices related to covid19 are low among the poor and marginalized communities of central india there is high prevalence of stigma in these communities knowledge is positively correlated with attitude and practices whereas it is negatively correlated with stigma therefore it is necessary to provide effective risk communication messages to these communities through alternate channels all relevant data are within the paper and its supporting information files

covid19 has led to unprecedented challenges and requires local and global efforts for its mitigation poor and marginalized populations are more vulnerable to the health social and economic effects of the pandemic the objective of this study was to know about the knowledge attitude and practices towards covid19 among poor and marginalized communities in central india and the factors associated with them so that effective risk communication messages can be designed and community engagement needs and strategies can be identified a crosssectional survey was conducted using an interactive voice response system as part of the nishthaswasthya vani intervention which is a platform for dissemination of key messages related to covid19 social welfare schemes national health programs and other important information a total of 1673 respondents participated in the survey the mean knowledge attitude and practice scores of the respondents was 406 sd 167 out of 8 246 sd 118 out of 4 and 365 sd 073 out of 4 respectively more than 50 respondents exhibited stigma towards recovered covid19 patients n 347 and towards health workers n 384 catering to covid19 patients the factors associated with higher kap scores were education occupation age and primary source of information on covid19 there was a positive correlation between knowledge and attitude coefficient 032 and a negative correlation between knowledge and stigma coefficient 028 the knowledge and attitude scores related to covid19 were low among the poor and marginalized communities while the prevalence of stigma was high therefore there is a need for effective risk communication for these communities through alternate channels

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introduction in mid2019 i launched a study on the experience of stigma by women in poland who were involved in different types of sex work i collected data through indepth individual facetoface interviews carried out in places indicated by the interviewees this method of conducting research worked well in my previous project on the social organization of the work of escort agencies in poland unfortunately my research plans were thwarted by the covid19 pandemic and the restrictions introduced in poland regarding mobility facetoface contact with unrelated people and university regulations which in the early days of the pandemic basically banned and later significantly restricted the possibility of conducting facetoface research in this situation i decided to change my research focus and conduct technologymediated interviews like many researchers at the time these methods were an alternative way for me to collect meaningful data but i would not have resorted to them had it not been for the pandemic this is because i shared the belief that facetoface interviews are the gold standard for conducting interviews for this reason i initially viewed mediated interviews as a hindrance and a potential threat to the quality of my research having said so much i quickly noticed that interviews conducted in this way can be saturated deep and very long remote interviews have proved useful in many qualitative studies on difficult and sensitive topics researchers who have resorted to them indicate that the data thus obtained are in no way inferior in quality when compared with facetoface interviews that there are no major problems in establishing rapport that participants are satisfied with the way the interview is conducted and that some participants prefer them over traditional forms of research nonetheless i wondered what drove the high performance resulting from the use of overthephone and online interviews for my research what i regard to be a key factor is the participants more robust agency in exercising control over the setting and course of the interview this changes the power relationship between me as the researcher and the interviewees as played out amid an interaction power proves situational and is shaped by several factors much as i acknowledge the significance of all the aforementioned factors i intend to focus on one of them exclusivelytechnological mediation of the communication between a researcher and the participants there is a rising trend for research to be based on technological mediation hence it may be useful to consider what such mediation may alter in the way the researchers and the participants control the research situation and express their power it is for this reason that the purpose of this article is to analyze how the power relations between myself and the interviewees were shaped during the different phases of our exchange via videoconferencing and phone namely from the moment of establishing contact for project enrollment until the actual interview and its potential validation i examine this process by analyzing who of the parties involved had control over aspects of the interview and how they gained control i embrace an interactionist approach in recognition of the fact that all the power tensions and negotiations under analysis are subtle in nature and unfold in the background of the interactions between the researcher and the participant all the while the parties to the conversation strive to maintain a discussion answer questions and solve technical problems i also adopt a constructivist approach in which the researcher and the interviewee jointly construct the interview situation it is also my assumption that an interview is a hierarchical form of conversation i acknowledge the significance of fostering such interview conditions to elicit power shifts between interactional partners the said conditions should engender a framework for the participants to boldly demonstrate their active attitude and display the scope of their power facetoface interviews might readily meet such criteria however it is my intention in this paper to bring out those aspects of indirect interviews that help accommodate the requirements of those participants who shun direct interviews that do not provide them with safety and comfort as was the case of my own study with sex workers although it takes far more than merely holding a remote interview for the relationship between the researcher and the participant to reach affinity with an egalitarian exchange i consider the remote profile of an interview to be facilitatory in this regard the conclusions disclosed in the article are particularly relevant to interviewees who experience stigmatization and marginalization and thereby show greater sensitivity towards control and power throughout the study it is precisely for these participants that indirect communication may prove to be an essential prerequisite for an active cocreation of the interview situation in terms of their specific needs the qualitative report 2023 in this article i focus on the power issue in technologymediated qualitative interviews which is still under investigated in publications this is because other authors mainly pay attention to the advantages disadvantages and practical issues associated with the use of this type of interview only mentioning in passing that it can contribute to power equalization between the researcher and the interviewees the article can facilitate a better understanding of how power relations are shaped during qualitative overthephone and online interviews and as a result help to make informed decisions about their application not only in situations forced by a pandemic geographic dispersion of participants or lack of finances but also because of what type of power relations the researcher wants to foster in the study i begin the article with a consideration of power in qualitative interviews with a particular focus on mediated interviews in the next section i present the study i conducted on the social stigma experienced by female sex workers in poland which is the basis for my further reflections i then discuss how i and my interviewees acquiredsharedgave up of control over aspects of the interview situation in its subsequent phases the article concludes with discussion sections and remarks on the limitations of my research power relations in qualitative interviews a qualitative interview is not a conversation between two peers on equal terms it is influenced by cultural constructions of similarity difference and significance the uneven allocation of power in an interview can be traced to differences in socioeconomic status educational or professional background gender age sexual orientation and ethnic identity of the parties involved while these do not necessarily reflect the researchers advantage over the interviewee in every case in many studies the interviewees may feel that they are on the weaker end of the interaction as a result the relationship between the interviewer and the interviewee is conceptualized as a power relation with an inherent power imbalance a traditional positivist account of the interview assumes that the researcher should hold control or power over the respective aspects of the interview an interview is usually viewed as a oneway dialogue in which the role of the interviewer is to ask and the interviewees role is to answer thus the active party in the interaction is the researcher it is the researcher who designates the venue and topic of the interview initiates the exchange poses the questions critically follows up the answers and closes the conversation it is the researcher as the expert who decides what data are incorporated into the research report and who predominantly benefits from the interview this facet was heavily criticized by feminist scholars who noted that the researcherinterviewee interaction can be potentially exploitative while traditional methodological approaches reproduce unequal power relations and reinforce the researchers epistemic authority the objections gave rise to research modes with a more participatory profile that by definition depart from the traditional positivist concept of the relationship between the researcher and the subject the use of positionality statements also inclines researchers to reflect on power imbalances and to take more informed actions towards study participants to shorten the distance between the researchers and the participants many researchers also employ various strategies such as selfdisclosure sharing their experiences and knowledge answering questions and expressing feelings however regardless of these actions the interviewee may still perceive the interviewer as possessing greater power new approaches to qualitative interviews recognize the active role of the interviewee who is also in a power position and can tip the situation towards the success or failure of an interview power shifts in an interview can be viewed through the lens of the concept of three dimensions of power proposed by lukes the first dimension refers to a situation where control is explicitly displayed and power is overt this can be seen for example when the interviewees refuse to answer a question interrupt the interview or start asking the researcher questions themselves the second dimension pertains to an indirect contest of power between parties through commanding controlling setting and influencing rules of the exchange dissuading actions and agenda setting the interviewee may resist the agenda and for example respond in a way that discourages the researcher from continuing a particular thread veer offtopic or remain silent finally the third dimension touches on what the parties value which stories and perspectives are privileged and reified and what is understood as the truth thus in a qualitative interview power shifts back and forth between the interviewer and the interviewee who are constantly seeking to equalize their respective authorities this conversational dance between the interviewer and the interviewee unfolds through interaction in the process of adjusting to each other interpreting each others actions and on that basis taking subsequent actions which make up the process of negotiating power during the interview power relations in mediated interviews researchers who relied on mediated interviews for their qualitative projects repeatedly made a point of such interviews having the potential to democratize the research process and equalize power relations between partners in effect they can foster conditions for empowering interviewees while it is difficult to point to a comprehensive discussion of this issue i discuss the changes in power relations between the researcher and the interviewees in qualitative interviews via phone and internet drawing on the available literature the key factor is the flexible setup of mediated research that allows for greater accommodation of the diverse needs of participants and their preferences in terms of the means of interaction as well as the timing and venue this facilitates an opportunity to engage those categories of interlocutors who due to busy schedules or limited mobility usually decline to participate most remote interviews are conducted by interviewees in the privacy of their own homes in their own private space while sitting on their bed or at their own desk thanks to physical distance virtual and phone interviews are less intrusive than when the researcher enters the participants home environment this is by virtue of a lower likelihood of the researcher accidentally or intentionally violating the interviewees established boundaries between private and public zones as observed by quartiroli et al the interviewees presence within a space they are comfortable with turns the odds in favor of their involvement with the interview which proves challenging in an environment where structured hierarchies of power are embedded the researcher can also designate the venue of the interview according to their liking and choose one they find most agreeable an opportunity that might not be available with facetoface interviews however should the interviewee be reluctant to turn on the camera the researcher may not have any input regarding the interview space the researcher also has no control over the factors that may breach confidentiality distract the interviewee or cause the interviewee to focus on certain threads and overlook others the researcher also has limited control over the technical side of the interview as there typically is no way of determining which equipment the participant employs the change in power relations derives from a stronger sense of anonymity on the part of the interviewees as opposed to facetoface interviews in remote interviews participants have more opportunities to withhold certain information from the researcher the fact that not all information can be gleaned from tone of voice or manner of speech can be interpreted as limiting the potential for both parties to confront issues of privilege and power within the research setting or alternatively an opportunity to conduct unbiased research above all interview participation may be encouraged by a sense of anonymity for those who tend to avoid involvement in research for fear of revealing their identity this is why mediated interviews make some interviewees feel more comfortable and confident than in facetoface interviews this is especially evident in those studies where there is a particular risk that the researcher can be seen as a figure of authority and control eg in research on youth and sensitive topics the physical absence of the researcher during the interview allows for reducing participants perceptions of risk of exposure or embarrassment reliance on mediated interviews diminishes the researchers control over the course of the study some researchers experienced an increased likelihood of alterations sometimes at short notice as well as participant absenteeism however this does not mean that interviewees notoriously shorten reschedule or cancel interviews over the phone and via voip as this has not been the case in many studies nonetheless physical distance certainly makes it easier for the participant to exit the interview they thus have a high degree of control over how much they contribute to the research under way this is particularly evident in remote interviews that are textbased in which interviewees can respond at their own pace and on their own terms often ignoring researchers requests however the shift in power from researcherdriven semistructured interview schedules to a more collaboratively constructed one can result in improving the quality of participants reflections a remote study may also be more ethically transparent the use of phone and online communication makes researchers more accessible to obtain informed consent researchers can send research information sheets and consent forms before the interview giving participants more time to read about the study and the opportunity to ask questions before the interview begins during a voip interview both parties have access to the recording which changes the arrangement of power since usually only the researcher has access thereto similarly the interviewees have complete access to the data they generate in an email interview as well so they can continue to revisit and construct their narratives throughout the process in other words mediated interviews promote settings that are more conducive to various modes of power expression by the participants this in turn may imply greater participation comfort an increased willingness for indepth reflections and better data quality materials and methods i am a sociologist who has conducted qualitative research on various aspects of female sex work in poland for 16 years initially embracing the perspective of sociology of work i was mainly concerned with the social organization of independent and managed indoor sex work however i gradually became increasingly interested in the topic of stigma which regularly came up during interviews and conversations with female sex workers upon becoming familiar with the stories of the women who participated in my research i came to acknowledge the severity of the negative impact of stigma on various aspects of their lives this holds true for the researcherinterviewer relationship as well since stigma can affect the course of interactions in this context as well as my experience shows hence i decided to start research on the various dimensions of sex worker stigma in order to better understand its mechanisms and thus contribute to its mitigation i conducted the research that serves as grounds for this article as part of a grant on social stigma experienced by female sex workers in poland although i started the project in 2019 i scheduled its main empirical part for the first half of 2020 which as it turned out was the time of the first wave of the covid19 pandemic due to the project schedule the precarious situation related to the unpredictable development of the pandemic as well as the contacts already established with several potential participants i decided not to discontinue the project merely changing the form to virtual interviews when arranging the details of the interview with the participants i offered them a choice of interviewing modalities either by phone via email or via videoconferencing skype i wanted the interviewees to choose for themselves whichever modality of contact they felt most comfortable with in order to create the most agreeable environment for them to talk about their difficult experiences of stigmatization a similar strategy was also adopted by other researchers who because of the pandemic changed their research plans from facetoface interviews to a mixedmode design that included remote types of interviews as it turned out the women with whom i negotiated the terms of their participation in the study readily agreed to mediated interviews especially online this may have been because there was a lockdown in poland at the time and educational pursuits at all levels and professional activities took place online thus virtual interviewing may have been seen as the obvious solution in this situation another reason may have been that most of the participants had past or current experience with online sex work and were comfortable with this mode of communication out of the 16 interviews completed two participants chose to be interviewed by phone with one additional virtually initiated interview the qualitative report 2023 but continued over the phone due to difficulties with the internet connection the remaining participants chose videoconferencing with either the camera on or off i opted for skype for videoconferencing purposes as it was the most familiar platform for me all the participants already had a skype account which they used for private andor business purposes in fact skype proved to be the most common communicator used in social research although zoom or microsoft teams may be on the rise as they were universally used for telework and online education during the pandemic in no instance did any of the interviewees choose to be interviewed via email nonetheless we exchanged numerous emails before and after each skype or overthephone interview these emails established the terms of participation and clarified or expanded on themes raised during the interview thus i used email not to conduct the actual interviews but as a supplementary method of data collection i adopted a twopronged approach to recruiting participants for my study using the snowball technique and through a sex workersled organization the selection of interviewees was followed by a theoretical sampling procedure thus i interviewed women from different segments of the sex work landscape with different seniority in sex work and of different ages during the period of my research the interviewees lived and performed sex work in five major polish cities it is also worth noting that most of the participants were students or had higher education and exhibited high communication skills the interview questions dealt with experiences of stigma in particular segments of sex work in relation to different categories of interaction partners the interviews conducted lasted from 100 to 235 minutes in keeping with the quality criteria proposed by kvale and brinkmann i rate the quality of the interviews as high the interviewees provided elaborate rich descriptive answers that were relevant to my questions with the interviews constituting complete stories with many details and indepth reflections that became the focus of interpretation throughout the interviewing process some interviewees were compensated for the interview as mutually agreed out of these some asked to donate their compensation to an emergency fund organized online by the sex work poland collective to financially support the sex worker community during the pandemic the article is based on an analysis of my field notes which i drafted from the time i first contacted each of the interviewees until the last email exchange the notes were used to record my observations and interpretations of my and the interviewees words and actions i fleshed out my notes in conjunction with the transcription of the interviews when i carefully reviewed the recording revisiting the video or audio for scrutiny multiple times allowed me to notice many interaction nuances that i had missed during the interaction itself in total i collected 58 pages of notes i treated the notes as a further type of collected data and subjected them to open coding according to the procedures of grounded theory which i adopted throughout the project after generating detailed open codes i proceeded with axial coding centering around codes related to categories of power and control during the interview the main category that emerged from the data was the negotiation of power between me and the interviewees in this article i present the category of negotiation of power in chronological order as it emerged and by pointing out its subcategories and properties results i define the category of negotiation of power between me and the study participants as derived from data analysis as the mutual attunement occurring during the interactions involved in planning conducting and analyzing a remote qualitative interview i construe the term negotiation broadly both as verbal explicit communication and implicit communication i also construe negotiation through nonverbal messages or the specific actions of each interaction partner negotiations pertain to individual elements of the interview situation and are subject to situational and temporal changes their result is the acquisitionsharinggiving up of control over a particular aspect of the interaction by its participants as a result the power in the interview situation resembles a mosaic as the partners have different degrees of control over different aspects of the interview situation in its successive phases negotiation of power prior to the interview the negotiation of power between me and the participants began with our first contact and proceeded through two subprocesses mutual identification of the position held and negotiation of the terms of the interview the first contact was via email the women would respond to my email interview proposal or they would initiate contact themselves either by writing to my email address or from the sex workersled collective as it turned out later potential participants usually browsed for my name on the internet before contacting me to see how i had previously spoken and written about sexual services if possible they would also discuss prospective engagement in my research with friends i had already interviewed thus by the time we exchanged even one email the interviewees usually already had a lot of information about me and my study this was somewhat uncomfortable for me as i had limited control over what information was shared in the conversations and what the interviewees came across on the internet themselves i also had no means of reacting to or correcting any misconceptions about me nonetheless the findings of the potential interviewees examination of who i am may have been crucial in their decision to enroll in the study they sought to minimize interview risks by assessing whether i could be trusted whether i adopted the right research assumptions and whether the results of my research would be useful to them gathering information about the researcher before deciding to participate in the study seems to be particularly important for representatives of stigmatized groups who are afraid to participate in the research process because they do not want to be judged they are only willing to participate on their own terms upon verifying that they will get along with the researcher in my study if the women were knowledgeable of how previous interviews played out the negotiation stage was shorter however if this information was insufficient for them potential participants engaged in multiple email exchanges in which they inquired about issues of importance to them compared to the interviews with sex workers i had conducted facetoface in earlier years online interviewees asked far more questions about me and my views on sexual services my motives behind launching the study and its purpose the rules governing its execution and plans for disseminating the results i never heard many of these questions from interviewees in traditional interviews at the same time the potential interviewees took strategic positions towards me although they asked me many questions they themselves were reticent to reveal information about themselves which worried me as i was concerned about their openness during the interview i could not find out much from the email and skype addresses the interviewees chose to contact me typically they shared the email they used for sex work if it was a private address it was one of several they had seldom used and rather not for conversations with friends or family in some cases the address contained first and last names giving the impression of real data disclosure but the names turned out to be pseudonyms as revealed during interviews the skype account usually contained a different pseudonym than the email and involved current or past sex work usage some accounts sported an profile picture but usually the womans face could not be seen at this stage there was a clear disparity of background knowledge between the interaction partners while the participants gathered information about me directly from me my previous interlocutors or by internet searches i relied solely on what they themselves were willing to tell me hoping to learn more during the interview during the exchange of emails we also negotiated the terms of participation in the study because of the participantcentered approach i did not prepare a uniform agreement for everyone we negotiated the terms of the interview individually to make it comfortable for the participants the timing of the meeting was also a subject of negotiation the women usually came up with the date and time of the meeting themselves arranging it so that they could give the interview in conditions that were comfortable for them or scheduled around their working hours thus interviews were held at very different times i adjusted my work schedule to these times and looked for a suitable place where i could conduct the interview by comparison with the facetoface interviews completed earlier i discussed ethical issues much more thoroughly with the participants the dynamics of an inperson meeting sometimes in notsointimate conditions meant that the participants usually listened to the information but rarely asked anything now it was different many interviewees inquired about various aspects of the study including anonymity interview authorization data storage and use it was advantageous that all our arrangements were archived in an email especially since i did not employ formal agreements due to the interviewees concern for anonymity and obtained consent for participation by email or verbally during the interview meanwhile the interviewees tended to take their time responding to my emails leaving me unsure whether they were pondering the reply had opted out or were simply busy i was under the impression that i was constantly waiting for emails and although i responded promptly it was the interviewees who determined the pace of the exchange its content and the outcome the prolonged stage of decisionmaking by the women on whether to participate in the study was also the testing ground of the first subtle interactional negotiations between us it was the women who decided whether they would continue the contact when they would send a response and whether my proposals suited them irrespective of whether the numerous questions from the participants were driven by their sense of insecurity about the interview or by the fact that they felt safer asking questions online i perceive it as an advantage of the mediated communication that this stage proceeded at a pace set by the participants and in a setting that was safe for them by my willingness to clarify and negotiate not pressing for an answer and accept their pace of communication i let the interviewees know that they had the time and room to decide in my opinion such an unhurried pace of terms negotiation enhanced the womens agency and allowed them to feel confident about their participation negotiation of power in overthephone and skype interviews during the interview stage there were key power transitions within the relationship between me and the participants i describe them in terms of control over specific dimensions of the interview control over the technical side of the interview in an online interview researchers are often concerned about the interviewees equipment and internet connection quality in my research however this asymmetry was reversed the interviewees had better equipment and faster internet than i did this was because many of them at least some of the time worked as camgirls and had a highquality camera computer and connection they were also more proficient in using voip in my opinion this made a big difference in our relationship as the interviewees assumed the role of competent participants in the interaction which reduced the power distance between us from the outset along the same lines any technical troubles were an opportunity to activate their expert role for example one of the interviewees helped me solve an audio transmission problem that prevented us from starting the interview since she had similar situations in the past such incidents brought us closer together because they required a shared commitment to making the quality of the interaction the best it could be so while neither party controlled the technical aspects of the interview both were involved in the ongoing monitoring of call quality and troubleshooting regardless of which side was affected likewise delays especially in vision transmission which did occur and were related to the speed of the internet connection required some work attentiveness and focus on both sides to properly interpret our nonverbal responses this fostered greater democratization of the research as both sides struggled with analogous difficulties selection of and control over the interview venue the research participants had control over where they were interviewed in most situations i didnt know where they were because they didnt explain whether they were in their apartment at their workplace or at a significant others home with their camera turned off i was left clueless however the interview location was also a variable for me i conducted interviews from whichever place was available in view of the current family situation pandemic restrictions and nonstandard interview times neither did i always keep the interviewer in the know as to where i was currently located it is my opinion that handling the interview location helped bridge the power distance and made us alike in our often subcomfortable residential circumstances skype interviews afforded the interviewees control over what i would and would not see from deciding whether to turn on the camera during the interview in hindsight there was a rule in place that once the women would not turn the camera on when answering my skype call they would leave it off till the end of the interview in consequence none of the reluctant interviewees was prompted to change their original decision to conceal themselves or their surroundings regardless of how the interview progressed if the camera was turned on at the beginning it remained on throughout the interview the interviews during which my camera was on and my interviewees remained unseen made me feel uncomfortable for this reason i usually followed the interviewees decision to turn the camera on or off and as a result our positions were symmetrical the interviewees who did use the camera did not apply any background masking software they were usually seated on the bed or at the table showing wide frame views so i could see the interiors of the room they were in notice the furnishings and assess its size one of the interviewees gave me a tour of the apartment she was staying in which she rented for her sex work the interviewees were eager to show their pets which was a relaxing break from talking about difficult issues unlike some researchers i didnt ask the interviewees questions about what i saw in their apartments unless they started talking about it themselves in this way i wanted to respect their right to give me as much information as they saw fit especially since a sense of anonymity was important to them i didnt use backgroundmasking programs myself either my only interference with what the interviewees would see was when i removed the notes containing the interview guidelines from their fields of view this allowed me to discreetly access them without distracting the interviewees it is worth noting that none of them asked me questions about my space thus it can be said that we tacitly and independently adopted the assumption of not noticing the space which only came forth when one of the individuals wanted to pay attention to it although it was the interviewees who chose the venue and timing of the interview in 6 cases there were other people in the apartment during the interview there were also several occasions when they interfered with the interview from my perspective thirdparty interruptions provided additional information there were also instances when the persons interrupting contributed to the interview providing additional information on some thread of the interview as they were also sex workers initially i interpreted these occurrences as limiting the participants control over the interview situation however upon reflection i realized that all the appearing subjects had been advised by the interviewee about the fact of pursuing sex work the interview and its topic thus it can be assumed that by arranging a specific day and time for the interview the interviewees were aware that there might be a virtual meeting between me and these individuals and this was not a problem for them from this perspective therefore the risk of curbing their control was negligible control over interview engagement vs multitasking some of the interviewees especially those who had the camera on were completely focused on the interview however some of those who had the camera off or were on the phone were perhaps engaged in other activities apart from answering questions in the case of one interview the sound of nails being filed could be heard in the background while during another the sounds of dinner being prepared could be heard it is difficult to determine conclusively whether these activities were indulged in by the interviewees themselves or by those in the room with them and why they were occurring specifically during the interview contrary to appearances this did not negatively affect the answers given which were extensive and saturated for this reason i did not respond to these actions in another interview during a prolonged conversation with me the interviewee postponed her next meeting a fact of which she informed me after the conclusion of our interview since it was a phone interview i was completely unaware of the moment and the way she contacted her next appointment the fact that i did not know exactly what was going on in the interviewees room makes it difficult to interpret such situations and showcases the fact that i had very limited control over the interview situation then again if the results are excellent in terms of data quality perhaps one should just accept such diminished control controlling the temporal dimension of the interview as i have mentioned the interviews were lengthy and since we were not constrained by commuting issues we treated the interview time flexibly the timing of the end of the interview was usually determined by another scheduled activity of the interviewee or by her roommates return on several occasions we arranged for a followup meeting at another time and all these meetings came to pass there were no instances of cancellations or unjustified postponements of interviews the two instances of postponement related to unexpected circumstances on the part of the interviewees and the interviews were held at the closest available date thus the interviewees did not abuse their power although they were the ones who had more control over the temporal dimension of the interview it was an area of flexible negotiation though with more sensitivity to their needs and abilities control over the course of the conversation throughout the interviews i assumed the role of an apprentice by design trying to inquire and learn as much as possible from the interlocutor an expert with respect to her experience in view of the theme of the interviews the stigma around sex work experienced by the interviewees i asked openended questions carefully deepening them and dropping topics that the interviewees were not ready to answer i followed the same approach in my previous facetoface interviews with sex workers in consequence i gleaned indepth data containing personal confessions and disclosures regardless of whether the interviews were held in audio only or mixed audiovideo modality what distinguished the remote interviews from the inperson interviews i had previously conducted was that throughout the interview the interviewees posed multiple questions about my motivations experiences or opinions which upended the traditional polarity of roles this may have arisen from the rapport established in my opinion however this was also due to the mode of the interview and the fact that there was not much power asymmetry between us the interviewees defined themselves as peers in the interaction the intimate ambience of the interview with each of us remaining in our own private spaces while being able to see each others faces rather closely was also conducive to my own disclosures in many of the interviews i spontaneously talked about myself in passing on various themes this helped build rapport and made me feel at ease although it was not a planned or thoughtout strategy and could lead to overdisclosure thus the interviewees embarked on various actions to tailor the interview situation to their needs this corresponded with my efforts to carry out interviews of the highest possible quality in such a way that the interviewees felt comfortable it is worth noting however that i was the one who initiated the recording and brought it to a close the attribution of specific interactional measures to the researcher may result in the interviewees expectation of direction and control of the interaction on the researchers part even if only at certain times in no the qualitative report 2023 instance did an interviewee ask to stop the recording or alternatively ask to delete a portion of the transcription at the authorization stage postinterview negotiations of power at the postinterview stage the interviewees were unlikely to actively negotiate the power relationship in our interactions and were willing to exercise it passively i interpret this as an expression of their ability to decide for themselves how much they would remain involved in the project postinterview contact after each interview we exchanged emails for interview authorization in the most sparing version and in the most expanded version for coverage of additional threads not raised during the meeting this stage varied greatly depending on the interviewee although i followed up with all of them in a similar manner i exchanged numerous emails with some participants while the contact broke off quickly with others and it is hard to say whether they were discouraged by a particular question lost interest in the study or perhaps did not have time to continue participating as a result it was difficult for me to say at which point the contact ceased this is all the truer given that the interaction can still be potentially resumed indeed it was not uncommon for me to receive an email even a long time after the interview from a participant in which she would revisit a thread follow up on it or solicit information our research relationships can thus be considered suspended rather than definitively terminated although it is up to the interviewees to decide when to revive them control over the collected data because the interviews were recorded using a dedicated skype functionality both parties had equal access to the interview recording which would be rather rare in traditional research conducted facetoface thus the data was not the sole property of the researcher who would exert ultimate control over it however while i did ask the interviewees for permission to use the data for research purposes i did not agree with them on how they would use the recordings and transcriptions neither did the interviewees at any stage address the issue i also have no knowledge of whether they used them at all and if so how they used them potentially they could have compared the recordings with my transcriptions shared them with relatives etc each interviewee was given a file with the interview transcription for authorization and some of the women sent their comments regarding the removal of certain information they had revealed in the interview we agreed on the wording of these passages in email communication however some of the interviewees did not send the interview authorization although this was usually an important part of negotiating consent for the interview it is hard for me to ascertain whether they grew so trusting of me during the interview that they no longer felt the need for authorization did not want to go back over their statements or did not regularly check the accounts they used for the study which were usually not their main accounts the lack of feedback may also have simply been an expression of the desire to discontinue contact control over data interpretation by continuing remote communication participants can also be included in data analysis i have not done so but i asked some of the interviewees about my interpretations of the content from the interviews i exchanged a few more emails with some women in this regard while others did not respond contact thus ceased gradually either through decreasing frequency of email exchanges or suddenly without explanation or notice it should be noted that involving participants in the interpretation and analysis stage is difficult even in fully collaborative research it is usually up to the researcher alone to decide what and how much to include in the report and publication thus it remains a challenge to break the asymmetrical relationship between the researcher and the participant during data analysis in summary the power relations in the interviews changed dynamically from intense negotiations at the beginning of our interactions to power shifts during the interview to passive rather than active use of power in the final stages of our interactions on neither side were their open expressions of power imposing the partys will rather there were more subtle shifts based on negotiating proposing asking and suspending contact both sides also manifested their vulnerability through disclosure joint work and solving technical difficulties interpretive efforts when social cues were limited or mutual recognition of each others roles in my opinion the interviewees did not feel that they were the weaker side of the interaction as evidenced by their sense of agency selfawareness and active profile during interviews discussion many researchers who adopt voip technology for interviews note that participants are appreciative of rapport convenience and simplicity and userfriendliness of remote interviews and even prefer online interviews when given a choice of methods this is especially true for participants with prestudy experiences of using a specific platform for synchronous videoconferencing an interesting interpretation was put forth by d m hoffman in conceptualizing the types of communicative preferences of participants d m hoffman notes that it is up to the researcher to decide which method to use to collect data whenever the project allows for the implementation of several methods for the achievement of the desired results researchers choose the one that is most convenient for them consistent with their communicative preferences which are often unarticulated and undiscussed providing interviewees with a choice of communicative channel is thus an action towards changing the power relations in the interview it is an expression of the fact that the researcher recognizes the diversity of communicative preferences of the participants and is willing to account for them in the design of the study for the sake of the participants comfort like communication preferences interviewees potentially also have preferences in terms of the distribution of power in the interview and for at least some of them the ability to negotiate it flexibly in remote interviews might be crucial to consenting to and being comfortable with participation it is my contention that it is advantageous to consider the diverse communication preferences of interviewees and their different sensitivities to the balance of power in an interview upon deciding on a data collection method for a project although mediated interviews may not play out equally well in all projects they may be the preferred mode of participation for some participants including groups experiencing stigmatization and marginalization the flexible form of technologymediated qualitative interviews in which participants can engage on their own terms may not only be important within the context of the interview but also more broadly in terms of their empowerment and recognition of participants right of selfdetermination it can be of importance to bring the moments of empowerment of the interviewees also to other stages of the research process over which the participants have less influence such actions can particularly give them an edge in negotiating and enforcing the ethical terms of the interview which is valuable for researchers who wish to put the ethics of care into practice it is advisable to point out some limitations of my research that may have influenced the results many authors note that limiting factors for participation in online research may include age financial situation health or more broadly digital exclusion of potential participants enrolled in my study was a specific sample of interviewees ie young welleducated and technologically literate women with expertise in online sex work the freedom with which they navigated the online world helped to maintain the contextual naturalness of the study at the same time they may have felt more comfortable communicating online than other groups of interviewees and as a result were more likely to participate in the study also the recruitment methods i used may have been more effective than other ways of finding interviewees online the research participants were very sensitive to the issue of power distribution in interactions and had extensive experience in negotiating it with clients they also suffered repeated violations of prenegotiated rules and were familiar with interaction partners attempts to impose their power they did not explicitly associate phone and skype conversations with private chitchat as is often the case with other categories of participants but also associated such conversations with the context of dealing with clients remote interviews may therefore have reinforced their willingness to negotiate power in their interactions with me perhaps then my interviewees proved more assertive than other categories of interviewees and from the outset of our interactions braced themselves to determine the terms of the interview that suited them ask for details and make a conscious decision to participate such negotiations were a staple for the participants i was the one who had to come to terms with it likewise the elaborate phase of profiling my position may also have resulted from the interlocutors professional experience and desire to gather as much relevant information about me as possible in order to decide whether it was worth agreeing to a meeting this phase might have proceeded otherwise had my own and my interviewees experiences of negotiating power in interactions been different i conducted this study under distinct circumstances during the first wave of the covid19 pandemic in poland marked by the most stringent restrictions on movement and social contact that were later gradually relaxed the positive reactions of the participants may have been related to the fact that some of them were not providing sexual services during this period and all of them wanted to share their thoughts and experiences during this difficult time the interviewees also enjoyed a robust internet connection and the residential freedom to be interviewed in conditions that they felt comfortable with at a different point in time and with less favorable venue conditions the results of the online interview could have been different on a closing note drawing on my research experience and the literature i would like to offer the observation that researchers have become more reliant on remote communication and mediated interviews in research practice it is advisable to consider such a scenario in advance and obtain the ethics committees clearance for both inperson and virtual interviews depending on the preferences of the research participants in effect at least some interviewees will feel more comfortable and secure throughout their interaction with the researcher which may also translate into the quality of the data collected author note izabela ślęzak phd assistant professor in the institute of sociology university of lodz her main areas of interest are the sociology of sex work and the sociology of interaction please direct correspondence to

sex workers may show extreme sensitivity to power relations during qualitative research due to the previous experiences of stigmatization and marginalization the purpose of this article is to analyze how technologically mediated communication between researchers and participants during an interview may influence the scope of control exercised by the interactional partners during the first wave of the covid19 pandemic i conducted 16 qualitative phone and videoconference interviews with female sex workers in poland discussing the social stigmas they encounter each interview was followed up with extensive field notes that were analyzed using the procedures of grounded theory methodology these very field notes serve as the basis for the paper herein as a result of the analysis i distinguished areas of power negotiated by the interviewer and interviewees in successive phases before during and after the interview the sense of control over the respective aspects of a study may contribute to the establishment of a more democratic power relationship between the researcher and the participants who belong to a population bearing a stigma

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modelling vaccination and antivaccination views on a network dealing with nonuniversal vaccination vaccinations changed our health and quality of life dramatically yearly cases of measles mumps or smallpox decreased by more than 98 since introducing a vaccine 5 formerly fearsome diseases are now rare in many parts of the world thanks to vaccination programs 11 yet due to a limited number of vaccines their cost views against vaccines and many more reasons including the fact that with more vaccines the spreading of a virus slows down which in turn tends to discourage more people from participating in the vaccination campaign 16 universal vaccination is almost impossible thus understanding the impact of limited vaccination is critical as it plays a relevant role during the covid19 pandemic vaccination strategies have two core objectives lower and delay the peak size and reduce the final infected population to limit morbidity 17 there are however many challenges for designing a vaccination strategy deaths can be prevented by first targeting highly vulnerable populations 3 yet targeting vulnerable populations might not reduce the viral circulation and might not reduce the final infected population particularly if the targeted population has limited social contacts another strategy is to target highly exposed people such as healthcare workers or with frequent social contacts as it could slow down the overall exposure to the virus other strategies for instance targeting young people or random individuals could also be proposed for a variety of reasons thus the relevance of being able to compare the expected outcomes of different vaccination strategies modelling immunisation in a population one of the first mathematical models in epidemiology was concerned with immunisation in 1760 daniel bernoulli predicted the impact of immunisation with cowpox upon the expectation of life of the immunised population 19 since then many models of immunisation have been constructed remarkably the susceptible infected and recovered compartments model proposed in 1927 by william ogilvy kermack and anderson gray mckendrick 20 has been extended for the application of a vaccine 17 21 22 23 24 nearly 100 years ago the lack of computational power meant that dealing with a high number of variables was nearly impossible and obtaining numerical results was very costly and so compartmental models in epidemiology were translated under many assumptions into differential equations algebraic solutions were more accessible than numerical results and gave rudimentary insights into the general behaviour of the dynamics of the disease 25 for instance this basic model can provide us with a rough idea of the number of individuals that would need to be infected to achieve herd immunity 18 in the case of a vaccine it was showed that uniform vaccination is always less effective than targeted vaccinations and the optimal strategy involves vaccinating specific individuals first 26 many of the implications of the sir and the svir models rely on simplifying assumptions such as an homogeneous population mixing and uniform recovery rate in recent years thanks to the gain of computational power and the development of specific tools and frameworks some of these assumptions have been relaxed particularly assuming an homogeneous population with homogeneous contacts the use of networks in epidemiology is a powerful tool to relax both as tagged nodes allow considering disease dynamics for heterogeneous population groups 27 and different distribution of the edges allows considering distinct types of contacts for example in the case of a sexually transmitted infection the sexual partnership network is a natural framework for modelling the disease 28 the contact network among people is frequently modelled as a strongly connected smallworldlike graph 2930 meaning that the path in the network needed to connect any two nodes is rather small or with many shortcut connections 31 with a welldefined scale for the degree distribution of the number of contacts of each node 32 the network structure has a major impact on the spread of infectious diseases and therefore on successful vaccination strategies 5283334 the basis of the disease models on a network is a compartments model but minor changes on the networks connectivity might alter results significantly furthermore the network structure appropriate for a given setting not only depends on the structure of the contacts of the population but on the infection itself 28 designing successful immunisation strategies need to consider the inhomogeneous connectivity properties of the network 35 an infected person even with a reduced number of contacts can pass the virus between separate clusters particularly if any of such contacts is a shortcut connection in the network 32 on a smallworld network all individuals even if they have a small number of contacts are within a few infections to be infected themselves on a different network structure some nodes have many more connections than others and the network as a whole has a powerlaw degree distribution as in the case of the network of sexual contacts which exhibits scalefree features 35 referred to as a scalefree network 36 on a scalefree network uniform vaccination is always less effective than targeted vaccination 28 scalefree networks are resilient to a few disconnections but are strongly affected by selective node damage if a few of the most connected nodes are removed the infection suffers a substantial reduction in its ability to propagate 35 control programs should be targeted towards the highly connected nodes and such programs will be much more effective than those that target nodes at random 37 these strategies however assume that all individuals would accept the vaccine if offered a targeted vaccination towards the most connected nodes will be highly ineffective if for any reason some of the central nodes refuse a vaccine the impact of those who reject a treatment has been analysed among distinct demographic groups 15 showing that nonadherence to a treatment such as a vaccine can greatly influence the needed coverage to eliminate transmission in the case of network structures the impact of nonadherence has not been explored and it is likely to play a significant role during the covid19 vaccination program opinion dynamics and antivaccination views an idea or an opinion such as views in favour or against a vaccine is transmittedfrequently as an intentional actfrom one person to another 38 through distinct types of interactions people want to persuade others to adopt an opinion 39 the views of others might have an impact on individual beliefs 40 who update their own opinion different ways to model not only different perceptions or ideas but to also the updating process of those ideasobtained through interactions with others or with some externalitiesaim at capturing why opposing views can emerge and coexist in a society even if all individuals try to reach a consensus opinion dynamics has been modelled through a variety of angles and techniques for instance kinetic models of opinion formation 41 meanfield analysis which usually leads to a system of differential equations 42 agentbased models and even epidemiological models 38 frequently two opposing opinions are assigned to the extremes of an interval say 1 1 individual opinions are modelled as a number s in that interval according to the posi tion with respect to the two opinions and through interactions individuals have some compromise and other elements such as memory loss 43 the presence of leaders 42 the ability to convince others with a different opinion 44 varying levels of assertiveness 45 the fact that more extreme opinions are more difficult to change 46 also confrontation with distinct views and opinions does not happen at random either because of the dynamic process through which opinions are updated 44 or because of preferential interactions people tend to be surrounded by others with similar views 45 as in the diffusion of a virus different network structures are a natural framework to analyse opinion dynamics ideas and opinions tend to propagate on a network between adjacent nodes 47 for instance opinion leaders who have a greater impact can be the hubs of the social network 42 whereas the distribution of online contents can pass through highly connected nodes on a network 48 the results observed of complex opinion dynamics are that a population might have relevant levels of polarisation or fragmentation 49 people tend to have more interactions with others with similar views so they are more frequently exposed to the information that aligns to their values 48 users tend to aggregate in communities of interest which causes reinforcement and fosters confirmation bias segregation and polarisation and leads to the proliferation of biased narratives fomented by unsubstantiated rumours mistrust and paranoia 48 existent communities adopt new narratives and work as echo chambers limiting the information their members receive to what they agree with and discarding contradicting points of view thus reinforcing their beliefs moreover repeated exposition to similar content increases the chances of believing it even when its plausibility is low 50 for example it was detected that political ideology predicts perceptions of covid19 threat 51 massive misinformation is becoming one of the main threats to our society 1248 and they have rapidly become central in terms of covid19 52 already for covid19 most of the misinformation detected involves reconfigurations where existing facts are twisted or adjusted to fit different narratives 53 with a vaccine for covid19 opposing views towards immunisation will become the crucial element especially if the propagation of the virus itself and if vaccination strategies are in any way entangled within the network of individuals who refuse it antivaccination views opposition to vaccination is as old as vaccines themselves the reasons behind antivaccine views are diverse including religious 54 and political beliefs 55 as well as concerns about their safety and effectiveness that are often based on misinformation perhaps the most cited case in the last decades is the theory that falsely links autism in children with the mmr vaccine a theory that has been debunked by several studies 56 but that is still used as an argument against vaccination by some groups the origin and motivation behind fake narratives are often unclear but they usually create a certain panic in the readers and encourage action such as sharing the news with family and friends 57 perceived altruism and solidarity with others is one of the main reasons people share unverified and often fake content 5258 vaccine safety concerns receive more public attention than vaccination effectiveness 11 people share false claims about covid19 and its vaccine since it is often difficult to detect whether some content is accurate 59 according to a 2018 study in 140 countries 60 79 of the global population perceive vaccines as safe and 84 as effective however these percentages vary greatly from region to region representing less than twothirds of the population in some areas especially europe and in the case of a covid19 vaccine a study published in august 2020 in 27 countries found that nearly one in four adults would not get a vaccine for covid19 8 and in some countries more than half of the population would not get it including poland and france the main reasons cited for not taking the vaccine were adverse secondary effects and doubts about its effectiveness misinformation amplified by social networks have eroded the public confidence on vaccination causing an increase in the number of outbreaks of diseases that were already controlled as happened for measles in 2019 13 currently there are still some critical questions concerning the covid19 vaccines still we do not know whether the immunisation of a vaccine would wane over time and so how long the acquired immunity would last 18 even with a vaccine if reinfection could occur persistent herd immunity may never be attained which then could lead to cyclic outbreaks and cyclic vaccination 1861 finally we do not know if a sufficiently large population would reject the vaccine delaying even more the process of obtaining herd immunity methods a population of n individuals is constructed with two attributes current age and age at death both age and death are sampled from a scaled beta distribution 100beta with α a 2 and β a 3 for age and 100beta with α d 5 and β d 2 for age at the moment of death 62 individuals with death smaller than age are resampled resulting in a simulated population with a median age of nearly 35 years and a median age at the moment of death of 75 years three network topologies are considered where the nodes represent the individuals and the edges their contacts either concerning their vaccine views or their physical contacts so they might pass the virus between them firstly a proximity network where nodes are located randomly on a square and pairs at a distance smaller than a certain threshold d are connected the proximity network tends to have a large network diameter since nodes only contact others located nearby secondly a smallworld network with a rewiring probability r the smallworld network has shortcuts between the nodes meaning that the network diameter is much smaller than the proximity network thirdly a scalefree network with power p the scalefree network has hubs meaning some nodes with a much larger number of adjacent neighbours the three networks have the same average node degree so that between different topologies only the structure of the network is altered although very young or elderly people tend to have fewer contacts we construct age and network independently for simplicity an svir model is constructed in the network as follows firstly some randomlyselected nodes are infected and the rest of the nodes are susceptible after the initial infection process a percentage ν of the individuals are vaccinated called the vaccination rate if the individual is susceptible she or he gains permanent immunity and is no longer capable of passing the virus but if the person was already infected the vaccine does nothing each time step which could be considered a day susceptible individuals in contact with an infected person are also infected with probability π when a node is infected it is moved to the recovered state after τ steps counting from the moment of infection a recovered node no longer passes the virus to others the process stops when the population has no infected nodes and that time is noted as t ie t is the duration of the epidemic see the appendix for more details on the parameters of the model after infection some of the individuals who recover might not survive it has been noted that in the case of covid19 lethality increases with age for simplicity we consider a linear impact of age so that a person with age y years does not survive with a probability of φy for some φ 0 the average number of years of life lost due to the pandemic denoted by d is computed as the sum of the number of years that people who passed away lost divided by the population size n vaccination strategies five vaccination strategies based on targeting people by their age or their position on the contact network are considered for the proportion ν of individuals receiving the vaccine • degreetarget the top ν nodes with a higher degree more connected nodes receive the vaccine first • centralityvaccinate the top ν nodes with the highest node betweenness • peripheralapply the vaccine to nodes with the lowest node betweenness • agevaccinate the top ν nodes with highest age first • randomselect a portion ν of the individuals at random the first three strategies are based on network attributes meaning that nodes are sorted depending on their degree or the node betweenness and the top ν nodes are vaccinated the age strat egy is based on node attributes and the last strategy uses no information about the nodes even though the vaccination strategies differ by country they are mainly based on prioritising vulnerable groups defined as those with significantly higher risk of severe disease or death and those with high risk of contracting and transmitting the virus the first group comprises elderly and adults with comorbidities the second health and education workers as well as lowincome persons living in dense urban neighbourhoods for which social distancing is difficult 6364 three of the strategies that we test try to emulate the above vaccination guidelines we identify the age strategy with the group of higher risk of severe disease and the degree and centrality strategies with the group of population with a high risk of infection and transmission it is worth mentioning that in practice individuals with a high degree can be identified by their activity but identifying those with high betweenness centrality is more complicated for example we could think of a comparing vaccination strategies we consider two distinct metrics for comparing vaccination strategies firstly from the population of n individuals from which a small group is initially infected vaccines are applied according to some strategy and the svir dynamic is simulated until no individuals are infected from the recovered individuals the casualties are simulated and the average number of years of life lost d is computed as the sum of the difference between death and age from individuals who passed away divided by the population size n although it is possible to simply count the number of casualties measuring instead the average years of life lost distinguishes between the death of an elderly person with a reduced number of years to live and the death of a young person a second metric to understand the impact of distinct vaccination strategies is the time needed for the dynamic to stop t ie the time after the population has no infected nodes both d and t are computed for a vaccination strategy and for a certain vaccination rate ν so that d age and t age are reported for the age strategy with a vaccination rate of ν and likewise for other strategies for a given network and a fixed vaccination rate and a strategy results might vary for two reasons firstly because the initial infected population is sampled from the population secondly because of the transmission of the virus itself susceptible individuals who are adjacent to an infected node are infected with a probability π on each time step and so the progression of the virus might change between different realisations even with the same initial conditions for this reason we simulate each vaccination strategy 500 times for different vaccination rates ν and report the intervals which contain d s and t s for the different strategies s here we consider a perfect vaccine that grants permanent immunity although in reality the level of antibodies of an immune person may drop below a critical threshold which could take individuals back into being susceptible 1923 diffusion of antivaccine views the diffusion process of antivaccine views plays a relevant role in the vaccination process and therefore in the evolution and the burden of the pandemic the social network is a crucial part of the diffusion process as antivaccine views are spread through contacts convincing other individuals of their views of the vaccine we construct a diffusion process on a network similar to the sir model but for the adoption of an idea 38 as follows initially all individuals are susceptible to antivaccine views and some randomly selected individuals have already these views although some individuals could be considered more susceptible we assume that all individuals are equally susceptible at each time step individuals with antivaccine views share them with all their contacts individuals exposed for the first time to antivaccine views make a permanent decision based on the persuasiveness θ of the ideas where θ ∈ 0 1 are the chances that an antivaccine view persuades the exposed individual a small value of θ means that most individuals are not convinced by antivaccine views and the opposite for a high value of θ since we assume that the decisions of people are permanent then on the first step only the neighbours of those who initially share antivaccine views are exposed to them then at each time step only the neighbours of individuals who were convinced on the previous step are exposed for the first time to antivaccine views and make a decision on the second step only the neighbours of individuals who were convinced on the previous step are then exposed to antivaccine views and so on each time step only the neighbours of individuals who were convinced on the previous step are exposed for the first time to antivaccine views and make a permanent decision the dynamic stops when no new individuals are convinced of antivaccine views at the final stage of this dynamic some individuals have antivaccine views some have been exposed to antivaccine views but do not support them and some individuals were never exposed to antivaccine views we assume that only individuals who share antivaccine views reject a vaccine and the rest whether they were exposed or not to the views will accept to be immunised if a vaccine is offered a similar sir model for the covid19 social media infodemic was constructed although not based on a network but based on the spreading parameters 65 results considering a scalefree network with n 5000 individuals and 250 infected individuals at time t 0 targeted vaccinations yield drastically distinct results than a random vaccination strategy applying the vaccine to central nodes not only protects them from receiving the virus but also slows down its diffusion process allowing nearby infected nodes to recover and stop passing the infection to others the final size of the recovered population varies considerably for example considering a random vaccination strategy with a proportion of immunised people of ν 20 a large part of the population would be infected at a point with targeted vaccinations the size of the infected population drops drastically and therefore most of the individuals remain susceptible even with the same vaccination rate ν 20 without a vaccine the simulations show that the population expects to suffer up to 47 years of life lost due to the pandemic with a universal vaccine the loss is negligible yet a random vaccination strategy with rate ν 60 has the same impact in terms of life saved than a degree or centrality strategy with ν 30 in a population in which some individuals are much more connected than others or one in which individuals are just a few nodes away from each other targeting nodes with a high number of neighbours or nodes with a high betweenness yields similar results in terms of the years of life saved on a proximity network which has no nodes with a high number of neighbours or shortcuts the life lost due to the pandemic is smaller as the virus propagates slower and among fewer nodes nonetheless a degree strategy still reduces the burden of the pandemic particularly if the vaccination rate is small surprisingly targeting the most vulnerable population does not give better results in terms of the years of life lost than a random strategy as it does not slow down the diffusion process of the virus as much as the degree of the centrality strategy the peripheral strategy gives the worst results in terms of the years of life saved as it targets the nodes less capable of slowing down the viruss diffusion or decreasing the number of deaths the age strategy does perform better than the random strategy in terms of the number of casualties but not in terms of the years of life lost measuring only casualties does not give sufficient information and the demographics of the population who passed away should be taken into account the age strategy targets individuals who are more likely to pass away but it does not save much more years of life than the random strategy as it prevents casualties from people with a shorter remaining life expectancy provided that the potential correlations between age and centrality are ignored however elderly people tend to have fewer contacts 3 so targeting them with a low vaccination rate could imply some peripheral vaccination as well vaccination particularly with a low rate ν slows down the viruss evolution and thus it also slows down the time for the process to finish without vaccination it takes around 130 steps for the virus to spread across the population and for them to recover applying a vaccine to the most connected or the most central nodes prevents the virus from spreading to many nodes however it still moves through the network between less central nodes taking up to twice as many steps for the pandemic to end compared to the case with no vaccine the age and the random strategy also friction the evolution of the virus and therefore it also takes longer for the pandemic to end with degree centrality age and even the random strategy applying the vaccine to only some individuals delays the end of the pandemic only if a very large part of the population gets vaccinated the pandemic finishes faster than without any vaccine the peripheral strategy on a scalefree network accelerates the end of the pandemic since it immunises individuals who would be infected last as opposed to the case of a smallworld network on a smallworld network less connected nodes still pass the virus to their neighbours therefore low vaccination rates delay the epidemic process increasing the duration of the pandemic t s notice that although the svir model is a dynamic process it is based on a static network of individuals meaning that no new connections are formed however if the vaccine process takes longer it is likely that new contacts are added to the network with its possible implications in terms of the years of life lost d s and the time t s the topology of the network the topology of the social network plays a relevant role in detecting the optimal vaccination strategy and its impacts on saving lives and speeding the pandemic process targeting the most central or the most connected nodes on a scalefree network rapidly decreases the years of life lost for some schematic representation of a scalefree network with power p 1 with larger and brighter nodes displaying their node betweenness the evolution of the svir model for the random and degree vaccination strategies with the same vaccination rate ν 20 shows that the majority of the population will remain susceptible under the targeted degree vaccination strategy but that a large part of the population will be infected and recovered under the random strategy the final state of the nodes shows that many nodes are recovered with a random strategy but most remain susceptible with a degree strategy vaccination rates but it is slightly less effective on a smallworld network and has a limited impact on a proximity network compared to other strategies qualitatively speaking except for the peripheral vaccination strategy a smallworld and a scalefree network show similar results targeting the vaccine to the most central or the most connected nodes reduces the casualties although for low vaccination rates it increases the time for the pandemic to end targeting the most vulnerable individuals has an impact as reduced as the random vaccination strategy and for low vaccination rates both will increase the time t s when central nodes are removed through vaccination fewer individuals will be infected but the virus takes longer to propagate so the time t s nearly doubles as compared to the scenario with no vaccination a strategy targeting the younger nodes could also be designed but due to their small lethality that strategy saves fewer years of life and prevents fewer casualties than any other strategy the time t s of such strategy follows the same patterns than the age and the random strategies since none of those strategies uses the network properties antivaccine views antivaccine views strongly depend on the persuasiveness θ for small values of θ the idea dies fast and only a few individuals ever share those views as with an infection most of the individuals remain susceptible for medium values of θ many individuals will have heard of antivaccination views although many of them will not be convinced by them only with high values of θ antivaccination views percolate the network the final size of the antivaccination community depends in a nonlinear way on the persuasiveness θ and the networks topology more central nodes are more exposed to antivaccination views than peripheral nodes in turn assuming that nodes are equally likely to adopt antivaccination views the first time they are exposed to them more central nodes are also more likely to share antivaccination opinions the top 10 most central nodes are between two and three times more likely to share antivaccination views than the 10 least central nodes for a small persuasiveness θ for different vaccination rates ν and the corresponding time t s with the same vaccination rate three network topologies are tested a scalefree network in the left a smallworld network in the middle and a proximity network in the right all networks with an average node degree of 6 each strategy is simulated 500 times with n 5000 individuals with a probability of infecting neighbouring nodes at each step of π 005 and with a varying vaccination rate ν the lethality of the virus increases with φ 005 meaning that a person with y years does not survive after being infected with a probability of 005y for small values of persuasiveness θ most individuals have contact with the antivaccination views even if they reject them and do not pass them onwards this can be particularly challenging as antivaccine views have many narratives including different conspiracy theories safety concerns the use of alternative medicine or medical risks such as autism 66 each narrative might follow similar dynamics reaching most individuals but convincing only some triggering collective narratives and creating echo chambers which reinforce themselves thus the diffusion of distinct antivaccination narratives could also be conceived as many realisations of the same dynamic each for separate views that convince different susceptible individuals antivaccine views are shared on a network of n 5000 individuals where some randomlyselected nodes initially share the views the top panel shows the evolution of those who are exposed for the first time to antivaccine views and are convinced by them those who are exposed for the first time but do not adopt them and individuals who never have contact with them the odds of a person sharing antivaccine views comparing the top 10 most central nodes against the bottom 10 shows that for extreme values of θ centrality does not have an impact but for values in between the most central nodes are two or more times more likely to share antivaccination views since they are more likely to be exposed since individuals are equally likely to adopt the views after their first exposure more central individuals are more likely to adopt them the impact is more pronounced on a proximity network even when the network does not have nodes with a high degree and a scalefree network than on a smallworld network by the end of the diffusion process of the antivaccination views even with a small persuasiveness θ most individuals will have contact with those views on a scalefree network with persuasiveness of θ 03 around 70 of the population has contact with the views the impact of the size of the antivaccine community is relevant in terms of the years of life lost d s and has some impact in terms of the time to finish t s considering a vaccination rate of 30 assuming a degree vaccination strategy we see that if 20 of the people support antivaccination views nearly two years of life are lost ≈ 2 years however with a vaccination rate of 03 and the degree vaccination strategy only 03 years of life are lost time convinced of antivaccine views not convinced of antivaccine views exposed to antivaccine views exposed to antivaccine views never exposed to antivaccine views years of life lost av top central vs bottom the final size of the antivaccine community is directly related to the persuasiveness parameter θ and the number of steps needed for the dynamic to stop is surprisingly short with a small persuasiveness θ the idea dies fast with a large θ the idea percolates in just a few steps only with intermediate values of θ there is some delay but it is still a fast process a virus might propagate fast but fake news and misinformation propagate many times more quickly finally assuming that the network in which opinions are shared is the same in which the virus propagates the antivaccination views impact is highly relevant and interferes with vaccination strategies considering a vaccination rate of 30 and a degree vaccination strategy 03 years of life are lost on a scalefree network and little more than a year on a smallworld network but that could increase to nearly two years if only 20 of the population shares antivaccination views more central individuals are the key aspect of optimal vaccination strategies as they slow down the diffusion process of the virus but their centrality also places them as nodes more likely to share antivaccination views thus having a substantial cost on the vaccination strategy a larger antivaccination community reduces the time to finish t s as the virus propagates faster except for a small range on a scalefree network only diffusion of antivaccination views and the virus on different networks opinions and antivaccine views are frequently shared on social media among distant individuals therefore the network in which antivaccine views propagate does not match the network in which the virus infects more people although there could be some interdependence if a person rejects a vaccine then the people with whom they have physical contact with are more likely to reject it as well as they will probably be exposed to antivaccine views therefore clusters of individuals will form who reject the vaccine and in which the virus spreads easily to detect the impact of different network structures on the process of vaccination and the propagation of antivaccine views first we construct the opinion network according to some topology then by dropping edges rewiring them or changing the topology completely we construct the contact network in which the virus is passed dropping some randomly selected edges from the opinion network to construct the contact network happens for example if two individuals are connected to each other through social media but they do not have any physical contact and thus the edge between them should be dropped for the contagion process formally the opinion network is constructed and then each edge in the network is kept with a probability ρ in the contact network with ρ 1 the contact network remains the same as the opinion network with a value of ρ 0 the contact network is empty but with values of ρ ∈ the resulting contact network keeps some of the aspects of the opinion network such as hubs but with fewer edges results show that dropping random edges considerably decreases the speed at which the virus spreads in the network thus reducing the final size of the recovered population and the life lost rewiring some randomlyselected edges of the opinion network to construct the contact network maintains some structure from the opinion network but creates shortcuts between nodes 29 increasing the burden of the pandemic this could happen if for example two individuals have some physical contact so that the virus can pass between them but they do not interact in terms of their opinions or views concerning the vaccine formally the opinion network is constructed as before with some predetermined topology and parameters then each edge in the graph is maintained with a probability ρ and it is rewired in any of the two extremes with a probability 1 ρ to a randomly selected node for values of ρ 1 the contact network is identical to the opinion network but with smaller values of ρ the contact network exhibits some perturbations even for values of ρ ≈ 0 a node with a high degree is expected to keep a high degree after rewiring meaning that part of the structure of the network is kept rewiring even a small number of edges creates contacts between nodes which are far away and increases the years of life lost this is observed specially on the proximity network in which clusters of antivaccine individuals get in touch with others who may not have exposure to such views decreasing the collective benefit from the vaccination strategy on a smallworld network only with a small persuasiveness θ of antivaccine views rewiring cre ates contacts between antivaccine clusters and nodes that were not exposed so there is a high cost on rewiring considering that the propagation of the virus and the antivaccine views on distinct networks is the case when for example most of the debate regarding views in favour or against a vaccine happens online and rarely in person results show that the proximity network reduces the years of life lost when antivaccine views have a high level of persuasiveness but that with a small level of persuasiveness the scalefree network reduces the life loss since even a low vaccination rate minimises the propagation of the virus drastically if antivaccine views are seductive and they tend to propagate through a highlyconnected network with hubs and shortcuts most people will be exposed to such views if in addition there is a limited number of vaccines applying them to the most central nodes which are not against the vaccine will reduce the total burden of the pandemic further preventing shortcuts in the contact network and hubs lowers the number of years of life lost and the number of casualties even with a limited number of vaccines and seductive antivaccination views discussion a vaccine for covid19 will not be a silver bullet to end the pandemic and mitigate its impact beyond the logistics related to producing and distributing billions of vaccines worldwide most countries will face limited availability of the vaccine especially at early stages still outbreaks can be contained by a strategy of targeted vaccination combined with early detection 32 our simulations cannot be used to estimate the years of life lost we would experience due to covid19 for different vaccination rates since that requires considering comorbidities access to health services and many more factors still with a simulated population and pandemic we obtain a qualitative description of how the process might evolve considering a limited vaccination and antivaccination views the main benefit of a person being vaccinated does not rest just on the immunity that they gain but also on the fact that they stop spreading the virus to others as such targeting vaccination to more exposed people or with a high centrality on the network reduces the final size of the recovered population and the expected years of life lost as well antivaccine views will be highly relevant antivaccine views and in general fake news related to the virus are a second pandemic to defeat convincing individuals that a vaccine designed in a specific country will feed conspiracy theories and other narratives including its potential lack of testing and fasttrack design a vaccine for covid19 would raise many questions and people often find missguiding incomplete or entirely wrong answers to all of them on social media antivaccination narratives offer a wide range of attractive and seductive explanations which could pull undecided individuals with genuine questions and concerns about the vaccine into their antivaccination views strictly enforced vaccination would blend perfectly with many of the conspiracy theories created around covid19 and would create massive chaos considering the reactions against a noninvasive element such as a face mask if universal vaccination in a country is offered still many individuals will likely opt to refuse it in turn the time needed to reach herd immunity might increase substantially although pandemicdenying opposing quarantines or face masks and antivaccine views are substantially different and are not necessarily shared by the same people a pandemicdenier for instance will most likely oppose being vaccinated against covid19 a person with antivaccine views likely has as many contacts as she where some randomlyselected nodes initially are exposed to the views and share them according to the persuasiveness θ of the antivaccination views the contact network is constructed based on the opinion network by dropping edges rewiring some edges or by changing the topology completely the number of years of life lost at the end of the pandemic are measured considering a vaccination rate of 30 and applying a degree strategy based on the degree of the contact network or he had before the pandemic and without keeping some physical distance to others or adopting safety measures would still pass on the virus if they get infected one of the severe challenges with antivaccine views is that they might be shared by individuals with high centrality in the social network as they are more exposed to them our results suggest that individuals with higher centrality are more likely to share antivaccination views which is detrimental for the results of an optimal vaccination strategy central nodes play a highly relevant role in the diffusion of antivaccination views and the pandemic evolution clear and concise evidencebased communication to the broad audience will be crucial to fighting against antivaccination views thus it is worth considering an efficient communication campaign as having a similar impact as a vaccination strategy among the most central nodes during the ebola crisis for example religious leaders across faiths in sierra leone advocated for practices such as hand washing and safe burials and their engagement was considered a turning point in the epidemic response 67 social media celebrities instagram influencers or youtube stars could help promote evidencebased views about the vaccine but could also act as hubs of misinformation an effective communication strategy targeting central nodes with shreds of evidence about vaccines in general and about covid19 could be viewed as an immunisation strategy against fake news which could percolate the network the propagation model depends on some assumptions such as the fact that all antivaccine narratives can be grouped and modelled within the same dynamics the fact that individuals make a permanent choice to adopt or reject the views or the fact that opinions are shared on a network between adjacent nodes the main parameters of the model were selected to mimic to an extent the covid19 pandemic including the propagation of the virus and the antivaccine views related to it expecting to obtain a general description of both issues but not hoping to obtain trends or forecasts concerning the pandemic other parameters particularly concerning the three network topologies and the rewiring algorithm were calibrated to keep the networks comparable in terms of their connectivity since a diffusion process would in general happen faster and have a larger recovered population on a network with higher connectivity thus the topologies used help us test a network with a large diameter the presence of shortcuts and of hubs considering the case in which nodes have the same average number of neighbours data availability code for simulating the svir dynamics and the propagation of antivaccine views using 6869 is available at githu bcomrafae lprie tocur ielvacci natio n appendix parameter calibration the models presented here for the diffusion of a virus and the propagation of antivaccine views are based on simplifying a complex reality the diffusion of the virus and the way it is shared among infected individuals who recover after some days and the gain in popularity of antivaccination views are both severe social issues for which no model will ever capture all aspects at an individual and a collective level social models are frequently incomplete and inaccurate aiming to capture emergent behaviours at a collective level often reducing most elements of the process to its minimal expression here the propagation of antivaccine views for instance is modelled as some permanent individual decision shared on some network main parameters used to model the propagation of some virus on a network under some vaccination rate and strategy where some individuals adopt antivaccination views in terms of the virus the three parameters are the probability of infection π the recovery time τ and the lethality φ and are somehow related the probability that a susceptible person is infected by an adjacent infected node is 1 τ ≈ 051 since they have interactions for a period of τ days the model parameters which are used to detect the impact of antivaccine views and to measure the results of a vaccination strategy are the vaccination rate ν and the persuasiveness of the views θ which are considered for all of its potential values in the 0 1 interval competing interest the authors declare no competing interests

misinformation is usually adjusted to fit distinct narratives and propagates rapidly through social networks false beliefs once adopted are rarely corrected amidst the covid19 crisis pandemicdeniers and people who oppose wearing face masks or quarantine have already been a substantial aspect of the development of the pandemic with the vaccine for covid19 different antivaccine narratives are being created and are probably being adopted by large population groups with critical consequences assuming full adherence to vaccine administration we use a diffusion model to analyse epidemic spreading and the impact of different vaccination strategies measured with the average years of life lost in three network topologies a proximity a scalefree and a smallworld network then using a similar diffusion model we consider the spread of antivaccine views in the network which are adopted based on a persuasiveness parameter of antivaccine views results show that even if antivaccine narratives have a small persuasiveness a large part of the population will be rapidly exposed to them assuming that all individuals are equally likely to adopt antivaccine views after being exposed more central nodes in the network which are more exposed to these views are more likely to adopt them comparing years of life lost antivaccine views could have a significant cost not only on those who share them since the core social benefits of a limited vaccination strategy reduction of susceptible hosts network disruptions and slowing the spread of the disease are substantially shortened major disruptions have been suffered at all social levels due to the covid19 pandemic with over 10000 daily confirmed casualties directly related to the virus during december 2020 and an increase of deaths related to other illnesses due to weakened healthcare systems 1 it will be among one of the leading causes of death of 2020 and it will have longlasting economic and social consequences surveys conducted in heavily affected cities suggest that a small part of the population has acquired covid19 antibodies 2 implying that we are far from reaching herd immunity through natural infection 3 furthermore considering a conservative infection fatality ratio and an optimistic herd immunity threshold several thousand casualties would still be suffered 3 with many vaccines already approved the biggest and most ambitious vaccination campaign in history has already begun the production and mass distribution of a covid19 vaccine will still be a major challenge for example robert redfield the director of the us centers for disease control and prevention cdc mentioned on a us senate hearing september 16th 2020 that he expects that with the availability of the vaccine the us public will return to their regular life around the third quarter 2021 4 in most parts of the world mass immunisation will not happen any time soon and therefore a targeted vaccination will be a key element to optimise the limited number of vaccines and to mitigate the impacts of the pandemic under this scenario unvaccinated individuals will still benefit from the immunity of those vaccinated since the reduction of susceptible hosts limits the spread of the disease 5 considering the global demand for the vaccine distinct vaccination strategies prioritising population groups with higher exposure to the virus or higher risk of severe disease or death will be a key policy particularly during the early stages of the vaccine distribution beyond the limitations related to the logistics of the vaccine opposition to vaccination will become central to any strategy for coping with the pandemic already for covid19 the use of a noninvasive item such as the mask has been highly polarising and rejected by some groups and protests and demonstrations around the world against the responses to the pandemic are frequent antilockdown protesters and conspiracy theorists have already demonstrated against the possibility of a mandatory vaccine as is the case with pandemic sceptics and socalled antivaxxers in london 6 whilst some conspiracy theorists burned 5g towers in the united kingdom 7 a survey conducted in 27 countries indicates that 1 in 4 people would not get a covid19 vaccine

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filipinos in a similar vein recent research has confirmed that individuals who reported higher ses tend to hold negative attitudes toward redistribution this is no surprise as economic growth and prosperity may make people from a higher ses group feel envious and insecure about outgroups perceived as rivals or threats as such they may respond to perceived status threats by supporting social policies that maintain or intensify inequalities and by opposing social policies that favour the lowstatus groups these differences in support for antipoverty programs can be understood within the frame of intergroup helping research on intergroup helping suggests that sociostructural context are systematically related to how group members construe the consequences of helping aimed at promoting inequality and chronic dependence or future equality and selfsufficiency the current research focuses on how perceptions of the stability of social stratification and construals of consequences of help might shape higher ses members attitudes towards antipoverty programs the social identity approach to poverty psychological accounts of poverty usually focus on the psychological outcomes causal attributions and the personality characteristics of the poor having said that poverty is more than scarcity of material resources it can be understood as a result of how social groups in societies make decisions about how to allocate valued resources within a given society thus the social identity approach serves as a fitting theoretical basis when examining poverty as it explains the psychological mechanisms of social categories and the relationships between social groups most studies in the tradition of the sia have focused on status inequalities in gender race or religion which make the topic of poverty underrepresented in the literature it has been recently argued that the key premises of the social identity approach are likely to be equally useful in deliberating socioeconomic inequalities the sia assumes three main social cognitive processes of how the gap between the wealthy and the poor can be understood as distinct psychological groups rather than as separate individuals first people categorise themselves and others in order to understand the social environment thus individuals ses based on income education and occupation are stable components of the social structure which provide the individual with a type of social identity parallel to gender and racial or ethnic identities second individuals embrace the identity of the groups they belong to as a result individuals adopt the identity of the group they have categorised themselves as belonging to third once individuals have categorised and identified themselves as part of a social group they are inclined to compare their group against another group poverty by definition involves comparison between wealthy and poor groups stability of social stratification on the basis of the key premise of the sia poverty is not only a problem of competing for valued resources but also the result of opposing social identities since members of the higher and lower ses groups are structurally situated at different starting positions within stratified societies they may respond to poverty differently lower ses members will aim to achieve higher wealth and status position whereas higher ses groups aim to maintain or protect their higher status position more importantly the main driving force that determines group members efforts at achieving a positive social identity is how they think about the social stratification past studies using the sia have consistently demonstrated the effects of sociostructural conditions on lowstatus group members status enhancement behaviours and highstatus group members status protection behaviours in relation to poverty the sia suggests that lower ses members responses to poverty are driven by relative deprivation perceptions whereas high ses members are driven by the stability of their position in the social stratification what appears to be emerging from the body of research on the social psychology of intergroup relations is an increasing interest regarding how higher ses groups respond to poverty when their status position in the social stratification is unstable when the social stratification is perceived as unstable high ses members will respond to inequality by diffusing threat coming from lower ses groups for instance perceptions of economic instability create fear that the status quo will change and that the boundaries between groups will become more changeable on the other hand when social stratification is perceived as relatively stable it is likely that higher ses groups will respond to inequality associated with sympathy toward individuals living in poverty from the recategorisation perspective the absence of status threat might reduce intergroup bias if higher ses members conceive the individuals living in poverty to be part of the same group then they would develop more positive attitudes toward outgroup members therefore poverty may shape perceptions of the sociostructural context thereby determining how high ses groups are affected by poverty and how they respond to it higher ses groups responses to poverty could be understood on the basis of their attitudes towards antipoverty programs attitudes towards antipoverty programs the old chinese proverb give a man a fish and you feed him for a day teach a man how to fish and you feed him for a lifetime is a succinct description of the conflicting attitudes towards antipoverty programs within the discourse of aid effectiveness dependency is commonly seen as undermining recipients selfsufficiency and its related terms such as autonomy independence selfsufficiency selfreliance and sustainability in the publics mind antipoverty programs are equated with dependency however antipoverty programs are created as a response to poverty that is aimed at promoting longterm selfsufficiency through education employment healthcare services and permanent housing cash transfer programs are the most applied antipoverty programs in response to poverty in many countries there are two different approaches regarding cash transfers which include conditional cash transfers and unconditional cash transfers the philippine government chose to implement the conditional cash transfer program due to its promising results in countries such as brazil and mexico these cct programs transfer the money to individuals who meet certain criteria research has offered evidence that the cct program has encouraged greater work efforts for its beneficiaries however critics perceived that the cct fosters dependency to its beneficiaries by giving them money with strings attached on other hand the unconditional cash transfer program provides money without any conditions for the receivers recent research confirms that unconditional cash transfers have significant impacts on economic outcomes and psychological wellbeing however by its very nature the line between conditional and unconditional cash transfer programs is still fuzzy at best forms of help the preceding argument about whether cash transfers should be conditional or unconditional might be based on how people construe the consequences of assistance offered to beneficiaries however there seems to be no available empirical research that clarifies the social cognitive processes that could explain peoples opposing perceptions and attitudes regarding the antipoverty programs to fill in this gap the current research seeks to clarify these divergent opinions regarding antipoverty programs by integrating the intergroup helping as a status relations model that supports the critical distinction between dependencyoriented and autonomyoriented forms of helping dependencyoriented help provides the lower ses beneficiaries with temporary aid from their problems but is less likely to help the recipients escape from the vicious cycle of poverty autonomyoriented help on the other hand refers to the provision of the tools that recipients need to solve their own problems and is therefore a potentially longterm solution for low ses beneficiaries moreover helping may be construed in different ways as more negatively or more positively promoting intergroup relations depending on the perceptions of status relations between opposing groups additionally the ihsr model incorporates the structural premise of the sia and the nature of help research has demonstrated that highstatus group members were strongly motivated to provide dependencyoriented help to members of a lowstatus group members when status relations were perceived as unstable since autonomyoriented help generates the idea that lowerstatus groups would challenge the status quo and undermine the dominant position of a highstatus group in the social stratification in contrast highstatus groups may endorse autonomyoriented help rather than dependencyoriented help towards lowerstatus groups when perceptions of intergroup status differences are not salient taken together the sia and ihsr models may serve as theoretical foundations in examining responses to poverty since perceptions of stability of the social stratification and the construals of forms of help appear to combine with high ses group members attitude towards antipoverty programs overview of the current research on the basis of the sia and ihsr models perceptions of the sociostructural context and forms of help are complementary psychological mechanisms that might clarify these conflicting perceptions and attitudes towards antipoverty programs two studies were conducted to test the current researchs prediction study 1 examined whether perceptions of unstable and stable social stratification might determine differences in support for hypothetical antipoverty programs construed as dependencyoriented and autonomyoriented help study 2s purpose was to replicate and extend study 1 by involving the real and contradictory antipoverty programs and decontextualise helping without constraining participants with regard to the consequences and the forms of help study 2 examined whether higher ses group members attitudes towards the cash transfer programs are driven by their perceptions of the stability of social stratification study 1 method participants and design the study focused only on higher ses individuals potential participants were recruited from the participant pool of a university known to be comprised of higher ses groups in cebu city philippines prior to the actual study they answered a screening questionnaire based on nonincome indicators of ses in the country such as whether the household head had completed a college degree or higher studied at private institutions owned at least two airconditioning units vehicles and other electronic devices had household helpers and had travelled outside the country for leisure according to the screening results 72 participants were identified as members of the higher ses brackets in the country participants were randomly assigned to the conditions of a 2 × 2 design procedure and materials at the beginning of the experiment participants were told that they were participating in a nationwide policy review study conducted by the philippine statistics authority participants were randomly assigned to read one of two editorials stability of social stratification manipulation two editorials were fabricated to look like pages from the countrys leading business newspaper in the unstable condition the editorial focused on presenting fictitious data on the narrowing income gap between the rich and poor it contained statements such as recently the data indicate that the gap between the countrys rich and poor is narrowing fast with low socioeconomic status groups enjoying significantly faster growth in incomes compared to members of the higher socioeconomic status groups in the stable condition the editorial focused on statistics on the widening gap between the rich and the poor manipulation check the effectiveness of the perceived stability of the social stratification was assessed by asking the participants level of agreement with the statement on the basis of the information provided the income gap between higher and lower socioeconomic groups would remain stable for years to come on a 7point scale ranging from 1 to 7 forms of help the second part of the experiment was an adaption from past research following this participants were told that they were participating in a national tax policy review regarding budget allocation for the proposed antipoverty programs all participants were asked to read four vignettes that described typical social problems faced by low ses groups in the country after each scenario participants were then asked to complete items that measure dependencyoriented and autonomyoriented help the items were modified to fit the context of the current study four items assessed dependencyoriented help i would support a small increase of 075 in my taxes if the collected money would allocated to programs that would be used for an antipoverty program that would help the high school students of low socioeconomic backgrounds receive loans that would help them pay for the first year of college i would support a small increase of 05 in my taxes if the collected money would be allocated to programs that would provide the unemployed heads of low socioeconomic households get contractual or projectbased jobs i would support a small increase of 05 in my taxes if the collected money would be allocated to a program that would help sick members of low socioeconomic families pay for treatment in public hospitals i would support a small increase of 05 in my taxes if the collected money would be allocated to a program that would help low socioeconomic households get loans to rent a house in a safe and affordable area four items assessed autonomyoriented help i would support a small increase of 075 in my taxes if the collected money would be allocated to a program that would help high school students of low socioeconomic backgrounds receive scholarships that would allow them to visit good colleges in the country i would support a small increase of 05 in my taxes if the collected money would be allocated to a program that would help unemployed heads of low socioeconomic households get trained to develop to the necessary skills to start their own business i would support a small increase of my taxes if the collected money would be allocated to a program that would help sick members of socioeconomic to become eligible and pay for health insurance to cover treatment in any hospitals i would support a small increase of 05 in my taxes if the collected money would be allocated to a program that would help low socioeconomic households get a loan to buy their own house in a safe and affordable area prior to the actual experiment a pilot test of the items was conducted to validate whether the items for each scenario presented were perceived as dependencyoriented or autonomyoriented help a twoway analysis of variance revealed that the items for dependencyoriented help and autonomyoriented help were perceived differently f 5287 p 001 η 2 74 as expected dependencyoriented items were observed as fostering dependency more than autonomyoriented items and autonomyoriented items were perceived as fostering selfsufficiency more than dependencyoriented items consistent with the past research the items were distinctively perceived as dependencyoriented and autonomyoriented types of help finally participants were debriefed and informed about the true nature and purpose of the study also they were explicitly encouraged to ask questions and clarifications regarding the details of the experiment results and discussion manipulation check the stability of the social stratification manipulation was effective a significant main effect for the stability of the social stratification was expected f 4177 p 001 η 2 38 in other words participants in the stable condition more than participants in the unstable condition thought that the differences between the higher and the lower ses groups would remain stable for years to come hypothesis 1 test a mixeddesign with repeated measures on willingness to support dependencyoriented and autonomyoriented antipoverty programs was performed the analysis reported an interaction between perceived stability of the status relations and nature of help f 17415 p 001 η 2 71 analyses of simple effects revealed that participants under the unstable social stratification conditions rated higher support for dependencyoriented antipoverty programs and lesser support for autonomyoriented antipoverty programs p 001 whereas participants under the condition of stable social stratification rated higher support for autonomyoriented and lesser support for dependencyoriented programs for the lower ses recipients p 001 as predicted higher ses participants mean ratings of support for dependencyoriented and autonomyoriented antipoverty programs significantly differed under conditions of unstable and stable social stratification participants of a higher ses group were willing to support a tax increase policy for dependencyoriented antipoverty programs and lesser for autonomyoriented antipoverty programs when they perceived the social stratification as unstable this finding adds to the body of empirical support for the sia and ihsr models by showing that perception of unstable social stratification sparks high ses group members desire to establish status hierarchy by supporting dependencyoriented forms of help for the poor in contrast higher ses participants who perceived the social stratification as relatively stable showed greater support for autonomyoriented antipoverty programs and lesser for dependencyoriented antipoverty programs such findings accord with earlier works that revealed highstatus group members are inclined to provide autonomyoriented help as long as the lowstatus beneficiaries were not threatening to their status position study 2 method participants and design a total of 76 individuals participated in the study with a mean age of 31 years ranging from 21 to 54 years before being selected as participants the adults were screened using the subjective status scale the 76 adult participants rated themselves above the midpoint of the scale participants were randomly assigned to conditions of a 2 × 2 betweenparticipants design on participants willingness to support the cash transfer program procedure and materials the experiment entailed a completion of a questionnaire that began with a cover story that the survey was about recent government programs this was followed by the random assignment of social stratification stability manipulation after reading the editorials participants were then told that the next phase of the study would involve their opinions regarding the existing antipoverty programs that would address the difficulties faced by the low ses families in the country participants were presented with photos of the low ses families and were told that these families were identified as beneficiaries of the national antipoverty program next participants were randomly assigned to read one of the two gazettes containing information about either of the two types of antipoverty programs types of cash transfers prior to the actual experiment a pretest was conducted to examine whether cct and uct could be perceived differently in terms of the consequences of help these volunteers were randomly assigned and asked to read one of the two cash transfer programs next they rated two items that asked the degree journal of pacific rim psychology to which they perceived the cash transfer program as promoting dependency to the beneficiaries and promoting selfsufficiency to the beneficiaries a 2 × 2 splitplot anova was employed and revealed a significant interaction between cash transfer programs and help items f 43689 p 001 η 2 88 volunteers assigned in the cct program perceived it as promoting dependency more than selfsufficiency and volunteers in uct program perceived it as promoting selfsufficiency more than dependency to the beneficiaries results might suggest that cct is predominantly perceived as promoting dependency more than selfsufficiency whereas uct as promoting selfsufficiency more than dependency dependent measure after reading one of the two gazettes the participants attitudes towards the cash transfer program were measured using five followup questions finally participants were asked demographic questions and were debriefed results and discussion manipulation check consistent with study 1 participants in the stable condition more than in the unstable condition thought that the differences between the higher ses and the lower ses groups would remain stable for years to come f 2672 p 001 η 2 27 thus the manipulation of stability of social stratification was successful hypothesis 2 test the mean of the five followup questions measuring willingness of the cash transfer programs was calculated for each participant and analysed in a 2 × 2 betweenparticipants anova the analysis revealed an interaction between perceived stability of the social stratification and type of help f 13256 p 001 η 2 64 analyses of simple effects showed that participants assigned in the cct program indicated higher mean ratings of support compared to participants in the uct program when they perceived the social stratification as unstable f 8622 p 001 η 2 40 however when social stratification were perceived as stable participants assigned in the uct program indicated higher ratings of support than participants in the cct program f 4896 p 001 η 2 40 in sum the findings of study 2 confirmed that higher ses participants attitudes towards cash transfer programs significantly differed under conditions of unstable and stable social stratification and types of cash transfers participants rated higher levels of support for the cash transfer program when social stratification was perceived as unstable and when type of cash transfer was conditional whereas participants rated greater levels of support for the cash transfer program when the type of cash transfer was unconditional and when the social stratification was perceived as relatively stable in theory perceptions of unstable social stratification reflect a desire to reinforce groupbased dominance by supporting antipoverty program perceived to promote inequality and chronic dependence however if groupbased perceptions that provoke detrimental status relations were repealed people might desire to support antipoverty programs perceived to promote future equality and selfsufficiency to the low ses beneficiaries however it is important to take into account that these pattern differences in perceptions regarding the two cash transfer programs did not imply that cct certainly fostered dependency and uct fostered selfsufficiency this result may imply however that the attitudes towards cash transfer programs could be construed differently depending on the sociostructural context general discussion overall the results of the two studies confirmed the current researchs general prediction that perceptions of the sociostructural context and forms of help were complementary psychological mechanisms that might shape these conflicting perceptions and attitudes towards antipoverty programs study 1 revealed that conditions of unstable and stable social stratification yielded pattern differences in levels of support for hypothetical antipoverty programs construed as dependencyoriented and autonomyoriented help particularly higher ses participants rated higher support for dependencyoriented antipoverty programs and lesser support for autonomyoriented antipoverty programs when social stratification was perceived as unstable whereas high ses participants who perceived relatively stable status relations rated higher support for autonomyoriented antipoverty programs and lesser support for dependencyoriented antipoverty programs study 2 confirmed that attitudes towards conditional versus conditional cash transfer programs were determined by perceptions of the social stratification specifically high participants rated higher support for the cash transfer program when the social stratification was perceived as unstable and the approach was conditional however higher ses participants in the stable social stratification condition were more willing to support the cash transfer program when the approach was unconditional theoretical contribution the current research clarified the social cognitive processes that elucidate contradictory attitudes regarding antipoverty programs such divergent attitudes regarding antipoverty programs could be based on whether people perceive it as dependencyoriented or autonomyoriented help which might be shaped by the perceptions of stability of the status relations the sia and ihsr models are ideal theoretical groundings in examining responses to socioeconomic inequalities since economic conditions shape perceptions of the sociostructural context and peoples construals of forms and consequences of help which may serve as the underlying structure for the formation of attitudes and opinions regarding policies and programs helping the poor further the results of the current research provided evidence to the recent sia to economic inequality among wealthy groups which hypothesised that responses to inequality by high ses groups were determined by their perceptions of the stability of social stratification with respect to the ihsr model it is important to acknowledge that the results of the current research cannot be fully acknowledged as a novel theoretical contribution nevertheless the current research makes a decent contribution to the broader literature of group processes and intergroup relations by replicating and extending the ihsr model in an underrepresented intergroup relation and economic influence limitations and future research some important limitations of the current research should be recognised for example both studies 1 and 2 plainly focused on participants construals of the antipoverty programs as dependencyoriented and autonomyoriented help such manipulations might not provide a precise differentiation of the antipoverty programs in terms of two types of help it is essential to recognise how the type of help should be appropriately conceptualised with regard to antipoverty programs thus future research might constructively examine robust experimental manipulations or direct reliable measurement of the two types of helping in relation to antipoverty programs the current research did not directly induce the perception of common identity which might clearly explain participants willingness to support autonomyoriented help thus future philippine research must incorporate the principles of recategorisation to promote positive intergroup relations in areas of longstanding conflict more importantly the present studies conceptually assumed a facevalue assertion of high ses groups with respect to the social identity approach to poverty and intergroup helping model future research could examine levels of the two natures of helping and the broader sociostructural context between members of higher and lower socioeconomic groups hence it would be reasonable to test the main effect of ses on type of help as mediated by perceptions of security of the status relations lastly the dependent measures were plainly selfreported reactions it is a given fact that selfreports are highly susceptible to social desirability influences within this line of work it would be interesting to examine the reactions via monetary allocation task for example harvey and bourhis examined differences in terms of money allocations made by the rich and the poor under conditions of wealth stratification

b uilding on social identity approach and intergroup helping as status relations model the current research examined the explored effects of stability of social stratification and forms of help on higher socioeconomic status ses members attitudes towards antipoverty programs two studies were conducted in a 2 social stratification stability × 2 forms of help design on willingness to support antipoverty programs study 1 examined the conditions of unstable and stable social stratification that might pattern differences in support of hypothetical antipoverty programs construed as dependencyoriented or autonomyoriented help study 2 replicated and extended study 1 by examining higher ses subjective participants attitudes towards the cash transfer programs conditional vs unconditional which were determined by their perceptions of the stability of social stratification overall the results of the two studies confirmed that attitudes towards antipoverty programs could be construed as specific forms of help dependencyoriented andor autonomyoriented help depending on the nature of the intergroup relations stability of the social stratification finally the theoretical contribution of the current research is discussed

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resumen este artículo profundiza en el debate actual sobre las interconexiones entre el proyecto de vivienda y el hábitat destacando cómo los momentos de crisis impulsan la innovación a menudo mostrada en exposiciones de vivienda el artículo propone tres enfoques clave para el proyecto participativo de vivienda incrementalidad diversidad tipológica y agrupación estos enfoques de proyecto reconocen la vivienda como un proceso dinámico y enfatizan la importancia de dar prioridad a la acción humana y la inclusión evitando la mercantilización de los hábitats humanos el artículo destaca la importancia de la colaboración transdisciplinar en la toma de decisiones sobre el proyecto de vivienda reconociendo la importancia de una variedad de factores vitales para promover comunidades urbanas resilientes e inclusivas concluye abogando por la educación y la investigación arquitectónicas centradas en la temporalidad como una dimensión crucial en el proyecto de vivienda esencial para abordar los desafíos cambiantes y dar forma a futuros urbanos sostenibles palabras clave crisis habitacional proyecto de vivienda colaboraciones transdisciplinares incrementalidad diversidad tipológica agrupación vivienda y hábitat un debate en curso las interconexiones entre el proyecto de vivienda y el hábitat se remontan a las discusiones arquitectónicas de los siglos xviii y xix sobre la cabaña primitiva 1 durante el siglo xx la noción de hábitat cobró protagonismo en el discurso arquitectónico después de la segunda guerra mundial impregnó el discurso del ciam sobre urbanismo 2 y la búsqueda del team 10 de rehumanizar los principios del urbanismo moderno 3 y promover el pensamiento ecológico en promote ecologythinking in architecture 4 the correlation between housing design and the creation of healthy habitats played a pivotal role in le corbusiers urban manifesto 5 and jane jacobss campaign for typological diversity in urban planning and design 6 various authors extensively studied the cultural dimensions of housing and its influence on defining habitats establishing a strong interdependence between housing design and the fundamental human need for shelter and inhabitation charles abrams in mans struggle for shelter in an urbanizing world explores the historical and social aspects of housing and its impact on habitats and communities 7 anthropologist amos rapoport delves into the cultural dimensions of housing and its reflection in shaping diverse habitat perspectives in house form and culture 8 william j mitchell investigates the transformation of urban habitats through digital technology in city of bits space place and the infobahn 9 urban historian dolores hayden provides a comprehensive analysis of suburban development and its influence on housing and habitat patterns in building suburbia green fields and urban growth 18202000 10 exploring a different geopolitical context abdoumaliq simone and edgar pieterse contribute with their new urban worlds inhabiting dissonant times to unravelling the intricate interconnections between habitat and urban life within the scope of rapid urbanization in the socalled global south 11 this summary of different takes on the interconnections between housing design and habitat have something in common while we argue that we live in a constant housing crisis since the industrial revolution we can also observe that new perspectives on habitat tend to surface in moments when the housing crisis gains central stage as a societal issue housing and the architectural discourse on habitat are interconnected with factors such as ecology shelter environment culture patterns of inhabitation urbanization economy health and wellbeing it encompasses essential aspects of human and nonhuman life these factors in different historic moments and geopolitical contexts can either act independently or align to trigger a widespread housing crisis according to the merriamwebster dictionary definition a crisis is an unstable or crucial time or state of affairs in which a decisive change is impending or a situation that has reached a critical phase 12 when we look at the global and persistent housing crisis this seems indeed like an incessant story never let a good crisis go to waste significant advancements in housing policy and design frequently arise in or after periods of crisis the most innovative concepts often originate from the urgent need for solutions and are associated with landmark housing exhibitions 13 these exhibitions allowed new ideas and solutions to arise freely because the absence of direct clients or residents meant that the borders of the possible could be reconnected in terms of building technology but also in cultural and social terms housing exhibitions serve as great examples of designdriven research they function as manifestos attempting to address important societal issues while introducing new ideals by physically realizing experimental designs on a full scale not only are they made visible but they can also be visited by both professionals and laypersons and ultimately they undergo the ultimate test actual habitation la arquitectura 4 la correlación entre el proyecto de vivienda y la creación de hábitats saludables desempeñó un papel fundamental en el manifiesto urbano de le corbusier 5 y en la campaña de jane jacobs por la diversidad tipológica en la planificación y el diseño urbano 6 varios autores estudiaron intensamente las dimensiones culturales de la vivienda y su influencia en la definición del hábitat estableciendo una fuerte interdependencia entre el proyecto residencial y la necesidad humana de refugio y residencia charles abrams en mans struggle for shelter in an urbanizing world explora los aspectos históricos y sociales de la vivienda y su impacto en los hábitats y las comunidades 7 el antropólogo amos rapoport profundiza en las dimensiones culturales de la vivienda y su reflejo en la configuración de diversas perspectivas del hábitat en house form and culture 8 william j mitchell investiga la transformación de los hábitats urbanos a través de la tecnología digital en city of bits space place and the infobahn 9 la historiadora urbana dolores hayden ofrece un análisis exhaustivo del desarrollo suburbano y su influencia en los patrones de vivienda y hábitat en building suburbia green fields and urban growth 18202000 10 explorando un contexto geopolítico diferente abdoumaliq simone y edgar pieterse contribuyen con su new urban worlds inhabiting dissonant times a desentrañar las intrincadas interconexiones entre hábitat y vida urbana dentro del alcance de la rápida urbanización en los denominados países en vías de desarrollo 11 este resumen de diferentes enfoques sobre las interconexiones entre el proyecto de vivienda y el hábitat tiene algo en común si bien sostenemos que vivimos en una crisis de vivienda constante desde la revolución industrial también podemos observar que nuevas perspectivas sobre el hábitat tienden a surgir en momentos en que la crisis inmobiliaria gana protagonismo como cuestión social la vivienda y el discurso arquitectónico sobre el hábitat están interconectados con factores como la ecología la vivienda el medio ambiente la cultura patrones habitacionales la urbanización la economía la salud y el bienestar abarca aspectos esenciales de la vida humana y no humana estos factores en diferentes momentos históricos y contextos geopolíticos pueden actuar de forma independiente o alinearse para desencadenar una crisis de vivienda generalizada según la definición del diccionario merriamwebster una crisis es un momento o estado de cosas inestable o crucial en el que es inminente un cambio decisivo o una situación que ha alcanzado una fase crítica 12 si analizamos la persistente y global crisis habitacional ésta parece de hecho una historia incesante nunca dejes que una buena crisis se desperdicie los avances significativos en la política y el proyecto de vivienda frecuentemente surgen en períodos de crisis o después de ellos los conceptos más innovadores a menudo surgen de la necesidad urgente de encontrar soluciones y están asociados con relevantes exposiciones de vivienda 13 estas exposiciones propiciaron nuevas ideas y soluciones porque la ausencia de clientes o residentes significaba que se podían alcanzar las posibilidades en términos tecnológicos pero también en términos culturales y sociales las exposiciones de vivienda son excelentes ejemplos de investigación impulsada por el diseño funcionan como manifiestos intentando abordar importantes cuestiones sociales al tiempo que introducen nuevos ideales al realizar físicamente proyectos experimentales a gran escala no sólo se hacen visibles sino que también pueden ser visitados por profesionales y profanos y en última instancia se someten a la prueba definitiva la construcción de la vivienda in 1851 during the renowned great exhibition of the works of industry of all nations also known as the great exhibition held in hyde park london where joseph paxton constructed his renowned crystal palace a cautious attempt was made to address the pressing challenge of finding costeffective housing solutions for the working class while striving to enhance living conditions adjacent to the official exhibition grounds allowing unrestricted public access a piece of land was allocated for the display of a new housing type that could accommodate four workingclass families the prince alberts model lodging house designed by henry roberts the designs for the great exhibition model dwelling derive from several years of experimentation by roberts 14 the plans were adaptable each floor could be repeated to four or five storeys while the pair of dwellings could become long streets of tenements the project acted as a catalyst for further work concerning designing housing for the labouring classes throughout the following decades numerous exhibitions took place across europe gradually paving the way towards improving the living conditions of laborers in the aftermath of the first world war architects influenced by the principles of the modern movement sought the solution for affordable housing focusing on optimizing living space specially through the design of efficient floor plans and incorporating spacesaving furniture and exploring new production techniques to enable the costeffective mass production of housing units in the period from the first world war until the second world war germany can be singled out as the country where housing exhibitions were intensely used as a vehicle to explore new habitat perspectives amidst the economic crisis in 1931 new concepts for living and accompanying dwellings were investigated as part of the deutsche bauaustellung in berlin en 1851 durante la great exhibition of the works of industry of all nations también llamada great exhibition celebrada en hyde park londres donde joseph paxton construyó su palacio de cristal se hizo un discreto intento de abordar el acuciante reto de encontrar soluciones de alojamiento asequible para la clase trabajadora al tiempo que se procuraba mejorar las condiciones de vida junto al recinto expositivo oficial que permitía acceso público sin restricciones se asignó un área para exponer un nuevo tipo de vivienda que podría albergar a cuatro familias de clase trabajadora la model lodging house del príncipe alberto proyectada por henry roberts los proyectos de la great exhibition model dwelling derivan de varios años de experimentación por parte de roberts14 las plantas eran adaptables cada una podía repetirse en cuatro o cinco alturas y cada par de viviendas podía convertirse en largas hileras a lo largo de las décadas siguientes se llevaron a cabo numerosas exposiciones en toda europa allanando gradualmente el camino en la mejora de las condiciones de vida de los trabajadores después de la primera guerra mundial los arquitectos influenciados por los principios del movimiento moderno buscaron una solución para la vivienda asequible centrándose en optimizar el espacio habitable especialmente mediante el diseño de plantas eficientes y la incorporación de muebles que ahorraran espacio y explorando innovaciones técnicas que permitieran la construcción rentable de vivienda masiva en el período comprendido entre la primera y la segunda guerra mundial alemania destaca como el país donde las exposiciones de vivienda se utilizaron intensamente como vehículo para explorar nuevas perspectivas del hábitat en medio de la crisis económica en 1931 se investigaron nuevos conceptos para vivir y complementar la vivienda como parte de la deutsche bauaustellung en berlín llamada die wohnung unserer zeit ocupó toda una sala de exposición con maquetas a escala real de viviendas o parte de ellas y fue organizada bajo la dirección de mies van der rohe 15 la presentó con la siguiente afirmación la vivienda de nuestro tiempo aún no existe sin embargo las cambiantes condiciones de vida exigen su realización el requisito previo para lograrlo es la identificación clara de las auténticas necesidades del habitar 16 la exposición también presentaba con optimismo maquetas 11 de villas espaciosas y lujosamente amuebladas pero era evidente que el énfasis principal recaía en el concepto de vivienda mínima y en las limitaciones económicas un año después también en el marco de la deutsche bauausstellung se celebró la exposición sonne luft und haus für alle martin wagner se convirtió en jefe del departamento de das anbauhaus al que rebautizó como das wachsende haus en consonancia con el nombre del grupo de investigación que había fundado en el otoño de 1931 17 dada la experiencia de martin wagner en los ámbitos de la racionalización y la prefabricación no es de extrañar que durante este período precario para la industria de la construcción abogara por la adopción obligatoria de elementos de construcción prefabricados y se erigió como el padre espiritual de la casa anticrisis la falta de capital dijo wagner nos obligará a desarrollar una construcción basada en componentes desde esta perspectiva propongo aprovechar esta pausa creativa involuntaria pero no necesariamente infértil en la industria de la construcción para pensar seriamente en la idea de la casa en crecimiento y desarrollarla aún más 18 en el período comprendido entre las secuelas de la segunda guerra mundial y el giro neoliberal de los años ochenta se hicieron intentos similares en diferentes contextos geopolíticos dos casos ilustran este fenómeno la exposición de vivienda de bajo coste en delhi india y el proyecto experimental de vivienda previ en lima perú la exposición en delhi fue organizada en con called die wohnung unserer zeit it occupied an entire exhibition hall with mockups of fullscale dwellings or parts of it and was organized under the leadership of mies van der rohe 15 he introduced the exhibition with the statement the dwelling of our time does not yet exist however changing living conditions demand its realization the prerequisite for this realization is the clear identification of genuine housing needs 16 the exhibition also optimistically featured 11 models of lavishly furnished spacious villas but it was evident that the primary emphasis lay on the concept of the minimal dwelling and financial limitations one year later also part of the deutsche bauausstellung the exhibition sonne luft und haus für alle was held martin wagner became the head of the department of das anbauhaus which he renamed das wachsende haus aligning with the name of the research group he had established in the autumn of 1931 17 given martin wagners expertise in the areas of rationalization and prefabrication it comes as no surprise that during this precarious period for the construction industry the global crises had caused an enormous downturn in housing production he advocated for the mandatory adoption of prefabricated building elements and emerged as the spiritual father of the anticrisis house the lack of capital wagner said will force us to develop componentbased construction from this perspective i propose using this involuntary but not necessarily infertile creative lull in the construction industry to think seriously about the idea of the growing house and to develop it further 18 in the period between the aftermath of the second world war and the neoliberal turn of the 1980s similar attempts were made in different geopolitical contexts junto con el united nations regional seminar on housing and community improvement y dirigida por jacqueline tyrwhitt experta en asistencia técnica de las naciones unidas 19 una de las principales características de la exposición fue un modelo de aldea a escala real proyectado para la vida comunitaria en zonas rurales que abogaba por viviendas pequeñas y asequibles y el uso de materiales locales20 la exposición de vivienda previ se centró en la producción en masa de viviendas incrementales de baja altura y alta densidad con especial interés en el desarrollo de sistemas constructivos innovadores y estrategias de agrupación la iniciativa experimental que comenzó con un concurso cuyo objetivo era encontrar un equilibrio entre las influencias conflictivas del crecimiento urbano informal y la planificación de arriba hacia abajo fue dirigida por peter land bajo el patrocinio de las naciones unidas reunió a arquitectos locales de perú con arquitectos extranjeros de renombre particularmente aquellos con logros notables en vivienda social como james stirling charles correa y aldo van eyck entre otros21 con la aparición y posterior dominio del sistema económico neoliberal la crisis del acceso a la vivienda se extendió por todo el mundo como un reguero de pólvora la mercantilización y financiación de la vivienda crearon condiciones perjudiciales para un acceso inclusivo a una vivienda adecuada en with the emergence and eventual dominance of the neoliberal economic system a crisis of affordability spread around the world like wildfire the commodification and financialization of housing created detrimental conditions for an inclusive access to adequate housing worldwide with a lasting effect in housing policy and design 22 in this context the housing debate shifted the focus from housing as a process to housing as a product to paraphrase the famous expression by john turner 23 a compelling illustration of the state of affairs concerning the interconnection between housing politics and housing design can be seen in the house vision exhibitions organised in tokyo on a regular basis since 2011 by a think tank led by japanese designer and art director kenya hara the house vision exhibition opens the doors for a collaborative project between designers and industry to generate awareness in society about alternatives to mainstream housing options this collaboration tries to overcome the menace of uniformity and mass production pushing the stakeholders involved in the project to incorporate the latest technologies in home electronics energy and mobility devices into architectural forms that could cater for the consumers perception of freedom of choice 24 this overview of housing exhibitions as venues where advancements in housing policy and design tried to tackle societal issues in moments of crisis is meant to illustrate two main ideas first one can say that in any given time there is always a housing crisis second while the trigger of the housing crisis keeps on shifting according to the zeitgeist it always invites a combined new approach in housing policy and housing design the future of housing today we are confronted once more with a housing crisis threating the sustainable urbanization of the world we live in over the course of the last century the process of urbanization has become widespread affecting regions across the globe and the speed at which this is happening is dauting by 2030 unhabitat estimates that 3 billion people approximately 40 of the worlds population will require access to adequate housing this translates in an overwhelming demand for 96000 19 a united nations regional seminar on housing and community improvement opened in new delhi on 21 january and ended on 17 february 1954 in conjunction with the seminar the indian government organized an international exhibition on lowcost housing one of the major features of which was a model village properly planned for community life in which none of the houses cost more than 5000 rupees the equivalent of a little more than 1000 dollars included in the village was a replica of the hut in which gandhi lived and worked todo el mundo con un efecto prolongado en la política y el diseño de la vivienda 22 en este contexto el debate desplazó el foco de la vivienda como proceso a la vivienda como producto parafraseando la famosa expresión de john turner 23 una muestra determinante de la situación relativa a la interconexión entre política y proyecto de vivienda se encuentra en las exposiciones house vision organizadas periódicamente en tokio desde 2011 por un grupo de expertos dirigido por el diseñador y director de arte japonés kenya hara la exposición house vision impulsa el proyecto colaborativo entre diseñadores e industria para generar en la sociedad conciencia sobre alternativas a las opciones convencionales de vivienda esta colaboración intenta superar la amenaza de la uniformidad y la producción en masa incitando a los participantes en el proyecto a incorporar las últimas tecnologías en electrónica doméstica energía y dispositivos de control que podrían satisfacer la percepción de libertad de elección del consumidor 24 esta descripción general de las exposiciones de vivienda como lugares donde los avances en políticas de vivienda y proyecto han intentado abordar cuestiones sociales en momentos de crisis pretende ilustrar dos ideas principales en primer lugar se puede afirmar que en cualquier momento puede haber una crisis habitacional en segundo lugar aunque el desencadenante de la crisis inmobiliaria sigue cambiando según el espíritu de la época siempre propicia un nuevo enfoque combinado en la política y el proyecto de la vivienda el futuro de la vivienda hoy nos enfrentamos una vez más a una crisis en el sector de la vivienda que amenaza la urbanización sostenible del mundo en el que vivimos a lo largo del último siglo el proceso de urbanización se ha generalizado afectando a regiones de todo el planeta y la velocidad a la que está sucediendo es preocupante en 2030 onuhábitat estima que 3 mil millones de personas aproximadamente el 40 de la población mundial necesitarán acceso a una vivienda digna esto se traduce en una abrumadora demanda de 96000 nuevas viviendas asequibles y accesibles por día 25 estas cifras hablan por sí solas de hecho el acceso a la vivienda es una condición previa al acceso al empleo la educación la salud y los servicios sociales con casi mil millones de personas que actualmente viven en barrios marginales construir vivienda digna y mejorar las condiciones de vida sigue siendo una cuestión crítica para la sociedad ante todo se trata de un desafío político indiscutible para abordar eficazmente la actual crisis onuhábitat sostiene que es necesario que todos los niveles de gobernanza otorguen a la vivienda una posición central dentro de las políticas urbanas y sitúen las personas y los derechos humanos en la vanguardia del desarrollo urbano sostenible pero el desafío no se limita únicamente a la naturaleza política o la construcción masiva de vivienda también se trata de explorar la interdependencia entre políticas y proyecto de vivienda incluyendo nuevos métodos de investigación estrategias experimentales de diseño y enfoques educativos basados en problemas como componentes clave para desarrollar futuros urbanos sostenibles en la europa occidental industrializada de los siglos xix y xx y en norteamérica la crisis de la vivienda se debió a esfuerzos inadecuados para erradicar la miseria y las enfermedades en comunidades urbanas de bajos ingresos si avanzamos hasta el presente el mismo problema afecta a las ciudades en rápida urbanización de los países en vías de desarrollo la reciente pandemia de covid19 ha puesto de relieve que la vivienda es un determinante social fundamental de salud y bienestar 26 a lo largo del siglo pasado los períodos de crisis económicas y políticas a menudo fueron acompañados de largas crisis inmobiliarias principalmente relacionadas con el acceso asequible a la vivienda 27 new affordable and accessible homes per day 25 these figures speak for themselves indeed access to housing is a precondition for access to employment education health and social services with nearly one billion people currently residing in slums building adequate housing and improving living conditions remains a critical issue for society primarily this is an indisputable political challenge to effectively tackle the ongoing housing crisis unhabitat argues it becomes necessary for all levels of governance to give housing a central position within urban policies and place people and human rights at the forefront of sustainable urban development but the challenge is not solely restricted to political nature or an issue of constructing large numbers of housing it is also about exploring the interdependence between housing policies and housing design including new research methods experimental design strategies and problembased educational approaches as key components to develop sustainable urban futures in 19th and 20th century industrialized western europe and north america the housing crisis stemmed from inadequate efforts to eradicate squalor and disease in lowincome urban communities fastforward to the present the same issue affects rapidly urbanizing cities in the global south the recent covid19 pandemic has highlighted housing as a critical social determinant of health and wellbeing 26 throughout the past century periods of economic and political crises have often been accompanied by enduring housing crises primarily related to affordability 27 and internal and crossboundary migrations 28 in different ways these crises contributed to shape human habitats through different housing policies that have a strong and enduring effect in the way we establish our social relations pursue economic opportunities and transform our natural and built environment to take stock on this phenomenon several studies have examined the correlations between the socioeconomic status quo and the housing policy of the moment 29 architectural historians have also tried to introduce migraciones internas y transfronterizas 28 de diferentes maneras estas crisis contribuyeron a moldear los hábitats humanos a través de diversas políticas de vivienda con un efecto fuerte y duradero en la forma en que establecemos nuestras relaciones sociales buscamos oportunidades económicas y transformamos nuestro entorno natural y construido para hacer un balance de este fenómeno varios estudios han examinado las correlaciones entre el status quo socioeconómico y la política de vivienda del momento 29 los historiadores de la arquitectura también han intentado introducir aspectos compositivos para comprender mejor las implicaciones espaciales de las políticas de vivienda en diferentes contextos históricos y geopolíticos 30 lo que permanece prácticamente sin abordar en los estudios sobre vivienda y hábitat es una explicación holística de cómo la toma de decisiones de proyecto se ve afectada y afecta a la vida cotidiana de las personas su ecología social y el medioambiente esta visión holística debería ir más allá de la figura clásica del proyectista y buscar las decisiones clave de proyecto integradas en manifiestos políticos agendas económicas programas sociales o políticas medioambientales por nombrar sólo algunos ejemplo de ello es la actual polarización entre las políticas de vivienda que exploran paradigmas opuestos de enfoques impulsados por la eficiencia o por la resiliencia 31 se considera que ambos paradigmas fracasan si no exploran un equilibrio entre sus ventajas económicas y sus implicaciones sociales esta es la razón por la que considerar el comportamiento de las personas como factor clave de diseño puede convertirse en una poderosa forma de crear sociedades mejores y entornos naturales y mejor construidos las implicaciones de esta propuesta son sin embargo enormes suponen ampliar las fronteras disciplinarias tradicionales que definen el trabajo de un arquitecto introduciendo campos como la microbiología la sociología la etnografía las finanzas y la salud pública por ejemplo esto no significa que los arquitectos y otros agentes involucrados en aspects of housing design to better understand the spatial implications of housing policies in different historic and geopolitical contexts 30 what remains largely unaddressed in studies about housing and habitat is an holistic account of how design decisionmaking is affected and affects peoples everyday life their social ecology and the environment this holistic account should go beyond the classic figure of the designer and search for the design decisions that guide the development of housing embedded in political manifestoes economic agendas social programmes or environmental policies to name but a few the current polarization of housing policies that explore opposing paradigms of efficiencydriven approaches versus resilience driven tactics is a case in point 31 both paradigms are deemed to fail if they dont explore possibilities to tradeoff their qualities and mitigate their fallouts this is why considering peoples behaviour as a key design factor can become such a powerful way of creating better societies and a better built and natural environment the implications of this proposal are however vast they involve expanding the traditional disciplinary borders that define the work of an architect penetrating fields such as microbiology sociology ethnography finance and population health for example this does not mean architects and other agents involved in housing design need to give way their expertise and become knowledgeable about all these different disciplines instead what is needed is further stimulus to enable transdisciplinary collaboration recognising the specific contributes each discipline can bring to the table and to include the enduser in what concerns the architecture discipline we argue that revamping the participation of different stakeholders in the design process is key for a more sustainable future in line with this we believe there are three factors that need special attention in this participatory housing design decisionmaking process time environment and community each of these aspects can be explored through a specific design approach respectively incrementality typology mix and clustering the contemporary perception of housing as a product static and commodifiable has contributed to the development of human habitats that lack a sense of identity and belonging housing neighbourhoods like those created in peripheral urban areas under the auspices of the brazilian program minha casa minha vida testifies to this 32 to counter this trend designers and policy makers should acknowledge housing as a dynamic process giving central stage to the agency of dwellers a stronger focus on incrementality will enable the emergence of designs that create dwelling environments able to accommodate growth and change through time the threat of the onesizefitsall approach that once was associated with mass production of typical housing blocks also associated with the paradigm of cost and time efficiency remains today it is the case for example in ethiopias integrated housing development program which demonstrates how the effects of housing programmes based on this paradigm can be highly disruptive 33 the collaboration between ethiopian central and local authorities and the german technical cooperation led to the creation of a uniform design for housing blocks that are rubberstamped across urban resettlement sites within the urban fabric and at the fringes of addis ababa to counter the detrimental effects of this typological monoculture typology mix performs a key role in enabling the development of projects responsive to different patterns of inhabitation aspirations and cultural backgrounds creating inclusive dwelling environments another aspect associated with the dominating neoliberal paradigm of efficiency concerns the lack of attention paid to the idea of community quantitative factors determine most of the housing el diseño de viviendas deban renunciar a su experiencia y adquirir conocimientos sobre todas estas disciplinas lo que se necesita es un mayor estímulo para permitir la colaboración transdisciplinar reconociendo las contribuciones específicas que cada disciplina puede aportar e incluir al usuario final en lo que respecta a la disciplina de la arquitectura sostenemos que renovar la participación de diferentes partes interesadas en el proceso de proyecto es clave para un futuro más sostenible en consecuencia creemos que hay tres factores que necesitan especial atención en este proceso participativo de toma de decisiones tiempo entorno y comunidad cada uno de estos aspectos puede explorarse a través de un enfoque de diseño específico respectivamente incrementalidad diversidad tipológica y agrupación la percepción contemporánea de la vivienda como un producto estático y mercantilizable ha contribuido al desarrollo de hábitats humanos carentes de sentido de identidad y pertenencia lo atestiguan barrios residenciales como los creados en áreas urbanas periféricas bajo los auspicios del programa brasileño minha casa minha vida 32 para contrarrestar esta tendencia proyectistas y responsables políticos deberían reconocer la vivienda como un proceso dinámico concediendo un escenario central a la intervención de los habitantes un mayor enfoque en la incrementalidad permitirá entornos habitacionales capaces de adaptarse al crecimiento y el cambio a lo largo del tiempo hoy persiste la amenaza del enfoque único que alguna vez se asoció a la producción masiva de bloques de vivienda ligados al paradigma de eficiencia en coste y tiempo es el caso por ejemplo del programa de desarrollo integrado de vivienda de etiopía que demuestra cómo los efectos de los programas de vivienda basados en este paradigma pueden ser muy perturbadores 33 la colaboración entre las autoridades centrales y locales de etiopía y la cooperación técnica alemana condujo a la creación de un proyecto unitario para bloques de vivienda que se extienden en áreas de reasentamiento del tejido urbano y en las periferias de addis abeba para contrarrestar los efectos perjudiciales de esta monocultura tipológica la diversidad tipológica desempeña un papel clave al permitir el desarrollo de proyectos que respondan a diferentes patrones de habitabilidad aspiraciones y orígenes culturales creando entornos de vivienda inclusivos projects designed to tackle the challenges of rapid urbanization 34 the lack of contact with the customs and everyday life of local communities often results in new housing areas that remain inhospitable and unable to become a safe environment for vulnerable groups such as the elderly and the children this is the case of the neverending neighbourhoods of matchbox houses developed in black townships of south africa under the postapartheid housing policy reconstruction and development programme 35 to tackle some of the problems associated with cases like the rdp housing housing design needs to consider clustering as a key design factor clustering is instrumental to enable the creation of habitats that can shape the association of dwelling units to create meaningful communities housing futures incrementality typology mix and clustering are key elements to inform and support the decisionmaking process in housing design they can play an important role in accommodating a new socioeconomic and ecological paradigm the case of aranya township a project designed and built in the 1980s in indore india can be used here to illustrate the vital importance of these factors seen from the vantage point of more than three decades since its construction the masterplan and project for the demonstration quarter was designed by the vastu shilpa foundation an organisation led by the indian architect balkrishna v doshi to cope with the crisis of affordable housing for the urban poor of india doshis project was preceded by lengthy studies of the vernacular tradition making sense of the sociospatial patterns of everyday life in the informal settlements near the projects location 36 informed by these studies and framed within the socalled sitesandservices housing policy sponsored by the world bank in the 1980s doshi and his team developed a project that demonstrates how design decisions can influence the production of inclusive human habitats in the aranya project doshi embraced the idea that architecture should be adaptable and incremental facilitating future expansion and transformation the projects fundamental objective was to empower residents by offering them the opportunity to actively participate in the construction and customization figure 8 aranya township as is stands today figura 8 municipio aranya en su estado actual otro aspecto asociado al dominante paradigma neoliberal de eficiencia es la falta de atención a la idea de comunidad los factores cuantitativos determinan la mayoría de los proyectos de vivienda ideados para enfrentar los desafíos de la rápida urbanización 34 la falta de contacto con las costumbres y la vida cotidiana de las comunidades locales a menudo da lugar a nuevas áreas residenciales inhóspitas e incapaces de constituir entornos seguros para grupos vulnerables como los ancianos y los niños este es el caso de los interminables barrios de casas como cajas de cerillas desarrollados en municipios negros de sudáfrica en el marco de la política de vivienda posterior al apartheid el reconstruction and development programme 35 para abordar algunos de los problemas asociados con casos como el del rdp se debe considerar la agrupación como un factor de proyecto clave la agrupación es fundamental para permitir la creación de hábitats que puedan dar forma a la asociación de unidades de vivienda para crear comunidades estructuradas futuros de la vivienda incrementalidad diversidad tipológica y agrupación son elementos clave para informar y apoyar el proceso de toma de decisiones en el proyecto de vivienda pueden desempeñar un papel importante a la hora de dar cabida a un nuevo paradigma socioeconómico y ecológico el caso de aranya un proyecto planteado y construido en la década de 1980 en indore india puede utilizarse aquí para ilustrar la vital importancia de estos factores vistos desde la perspectiva de más de tres décadas desde su construcción el plan director y proyecto piloto fueron realizados por la fundación vastu shilpa una organización dirigida por el arquitecto indio balkrishna v doshi para hacer frente a la crisis de viviendas asequibles en las ciudades de la india el proyecto de doshi fue precedido por largos estudios de la tradición vernácula sobre patrones socioespaciales cotidianos en asentamientos informales cercanos a la ubicación del proyecto 36 basándose en estos estudios y enmarcados en la llamada política de sitesandservices de vivienda patrocinada por el banco mundial en la década de 1980 doshi y su equipo desarrollaron un proyecto que demuestra cómo las decisiones pueden producir hábitats humanos inclusivos en el proyecto aranya doshi incluyó la idea de que la arquitectura debe ser adaptable e incremental facilitando la expansión y transformación futuras el objetivo fundamental del proyecto era empoderar a los residentes ofreciéndoles la oportunidad de participar activamente en la construcción y personalización de sus viviendas tras más de tres décadas desde su creación aranya presenta un sorprendente alejamiento del enfoque convencional de vivienda masiva que prevalece en la india el plan director incluye zonas para viviendas con parcelas de diferentes tamaños para atender a diversos grupos de renta evitando la estigmatización asociada a un monocultivo tipológico de viviendas para grupos de bajos ingresos además la organización de agrupaciones de vivienda fue planteada para desencadenar la consolidación de comunidades estructuradas este puede verse como otro de los grandes logros del proyecto de hecho al observar aranya hoy en día difícilmente se distingue si se trata de un proyecto de vivienda pública o un antiguo pueblo indígena que ha crecido orgánicamente con el tiempo además del papel clave que desempeñan los tres factores de proyecto planteados incrementalidad diversidad tipológica y agrupación las partes involucradas en el proyecto deben incorporar un proceso de toma de decisiones participativo para favorecer hábitats humanos capaces de hacer frente a desafíos futuros la reciente atribución del prestigioso premio mies van der rohe de la ue a la cooperativa de vivienda la borda de barcelona parece reconocer la importancia de este factor 37 el proyecto coordinado por el colectivo lacol muestra cómo las decisiones de diseño son clave para determinar opciones materiales y tecnológicas específicas acomodar diferentes estilos de vida y atender un enfoque de vivienda social económica y ambientalmente comprometido la borda puede y debe inspirar no sólo a responsables políticos y proyectistas sino también a educadores of their dwellings over three decades since its inception aranya presents a striking departure from the conventional cookiecutter approach to mass housing prevalent in india and various other regions the master plan includes areas for housing with different plot sizes to cater for different income groups avoiding stigmatization associated with a typological monoculture of housing for lowincome groups furthermore the organisation of housing plots in clusters was designed to trigger the emergence of meaningful communities this can be seen as another of the great achievements of this project in fact looking at aranya today one can hardly tell if this is a public housing project or an old indigenous town that has grown organically over time next to the key role played by the three design factors discussed above incrementality typology mix and clustering stakeholders involved in housing design need to incorporate a participatory decisionmaking process to enable the emergence of human habitats able to cope with the challenges of the near future the recent attribution of the prestigious eu mies van der rohe award to barcelonas la borda cooperative housing seems to acknowledge the importance of this factor 37 the project coordinated by the collective lacol shows how design decisions are key in determining specific material and technological options accommodate different lifestyles and cater for a socially economically and environmentally responsible housing approach la borda can and should inspire not only policymakers and designers but also educators conclusion the intricate relationship between housing design and habitat emerges as a continuous and dynamic architectural discourse tracing its origins from historical debates but remains valid to modern challenges it acknowledges habitat as encompassing both natural and built environments considering factors like site climate materials and cultural context in this article we wanted to specifically explore the integration of housing design and habitat considerations in correlation with housing politics as a driving force behind the architectural evolution of housing shaping urban landscapes and societal wellbeing through the lens of housing exhibitions we witnessed how crises have spurred innovation in housing policy and design these events underscore the importance of designdriven research to reshape housing paradigms the evolving narratives of housing and habitat also propels us to transcend disciplinary boundaries and adopt a transdisciplinary approach additionally acknowledging housing as a dynamic process also driven by the agency of its occupants can counteract the homogenization of human habitats and foster a sense of identity and belonging history has shown that crises can serve as catalysts for positive change by embracing innovation holistic thinking and participatory design we have the potential to forge a future of housing that not only addresses the current crisis but also embraces the evolving needs of humanity we examined specific aspects related with the enduring and widespread housing crisis to conclude exploring prospects for strategies to cope with present and future challenges related with housing design strategies like incrementality typology mix and clustering can act as vital elements to shape habitats that reflect the identity of its inhabitants fostering resilient inclusive and sustainable urban futures in architecture schools around the world teaching housing design often remains focused on either the spatial or the social depending on the teaching agenda of the staff or the institution while the socialspatial continuum is important and relevant it needs to be complemented with other dimensions one of the most important in housing design is temporality architectural education should pay more attention to time as a determining factor for design not only exploring the spatial and atmospheric qualities of a project as an idealized vision of a moreorless talented designer but also the real habitat inspired by everyday life and created to accommodate the multitude of different behavioural patterns diverse customs and changing routines temporality is the dimension that brings together the three design factors we discussed in this article incrementality typology mix and clustering new habitat perspectives should give a central place to temporality as a key dimension for housing policy and design conclusión la intrincada relación entre proyecto de vivienda y hábitat surge como un discurso arquitectónico continuo y dinámico que remonta sus orígenes a debates históricos pero sigue siendo válido ante los retos modernos reconoce que el hábitat abarca tanto entornos naturales como construidos considerando factores como el lugar el clima los materiales y el contexto cultural en este artículo queremos explorar específicamente la integración del proyecto de vivienda y las consideraciones del hábitat en correlación con la política como fuerza impulsora de su evolución arquitectónica dando forma a los paisajes urbanos y el bienestar social a través del prisma de las exposiciones sobre vivienda hemos sido testigos de cómo las crisis han estimulado la innovación en la política y el proyecto de la vivienda estos acontecimientos subrayan la importancia de la investigación impulsada por el proyecto para redefinir los paradigmas de la vivienda la evolución de las narrativas de la vivienda y el hábitat también nos impulsa a trascender las fronteras disciplinarias y adoptar un enfoque transdisciplinar además reconocer la vivienda como un proceso dinámico impulsado por la acción de sus ocupantes puede contrarrestar la homogeneización de los hábitats humanos y fomentar un sentido de identidad y pertenencia la historia ha demostrado que las crisis pueden servir como catalizadores de cambios positivos al adoptar la innovación el pensamiento holístico y el proyecto participativo tenemos el potencial de forjar un futuro de la vivienda que no sólo aborde la crisis actual sino que también incluya las necesidades cambiantes de la humanidad examinamos aspectos específicos relacionados con la duradera y generalizada crisis de la vivienda para concluir explorando perspectivas de estrategias que hagan frente a los desafíos presentes y futuros relacionados con el proyecto de vivienda estrategias como la incrementalidad la diversidad tipológica y la agrupación pueden actuar como elementos vitales para dar forma a hábitats que reflejen la identidad de sus habitantes y fomenten futuros urbanos resilientes inclusivos y sostenibles en las escuelas de arquitectura de todo el mundo la enseñanza del proyecto de vivienda a menudo permanece centrada en lo espacial o lo social dependiendo de la agenda del personal docente o la institución si bien el continuo socioespacial es importante y relevante es necesario complementarlo con otras dimensiones una de las más importantes es la temporalidad la educación arquitectónica debería prestar más atención al tiempo como factor determinante para el proyecto no sólo explorar las cualidades espaciales y atmosféricas de un proyecto como visión idealizada de un proyectista más o menos talentoso sino el hábitat real inspirado en la vida cotidiana y creado para acomodar diversidad de patrones de comportamiento costumbres y rutinas cambiantes la temporalidad es la dimensión que reúne los tres factores de proyecto analizados en este artículo incrementalidad diversidad tipológica y agrupación las nuevas perspectivas del hábitat deberían dar un lugar central a la temporalidad como dimensión clave para la política y el proyecto de vivienda figura 9 sesión participativa con futuros residentes y arquitectos de lacol cooperativa en el proceso de proyecto de vivienda colectiva la borda figura 8 rohan varma 2020 figura 9 fotografía reproducida con permiso de la borda lacol

the interconnections between housing design and habitat go back to the 18 th and 19 th century architectural discussions on the primitive hut 1 during the 20 th century the notion of habitat became prominent in the architectural discourse after the second world war it famously permeated the ciam discourse on urbanism 2 and team 10s quest to rehumanize the principles of modern urbanism 3 and to

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background in 2013 the number of asylum seekers and internally displaced people worldwide exceeded 50 million peoplefor the first time after world war ii the latest annual global trends report of the united nations refugee agency shows that 512 million people were forcibly displaced at the end of 2013 as a result of persecution conflict generalized violence or human rights violations 1 the huge number of 512 million displaced people includes 333 million idp and 167 million refugees with more than half of all refugees worldwide coming from just three countries afghanistan syria and somalia of all the refugees 86 are being hosted by developing countries with pakistan iran and lebanon hosting the largest numbers in addition to refugees and idp 12 million individuals are estimated to be seeking international protection and whose claim for refugee status has not yet been determined the majority of asylum seekers were registered in industrialized countries mostly due to political developments in countries of origin changes in asylum policies and practices in receiving countries and the fact that some countries are perceived as being more likely to grant refugee status than others 2 for the first time since 1999 germany was the worlds largest recipient of new individual applications with a total of 127023 asylum claimsfollowed by usa and south africa 1 hence the german health system faces new challenges by guaranteeing adequate healthcare provision to the rising number of asylum seekers access to health care for asylum seekers in germany is governed via the national law on services for asylum seekers the law is broad in conception but in practice it limits access to health services and emergency care services for this population and links it with lengthy bureaucratical procedures 3 this problem is long known and has been addressed by civil society organizations and health professionals through initiatives on different societal levels ranging from political campaigns to the provision of solidarity healthcare services furthermore the living conditions of asylum seekers the postmigration factors affecting their health and wellbeing as well as the difficulties they face in accessing health services have repeatedly been subject to public debate and scientific inquiry by scientists of different disciplines these inquiries are particularly important because the routine health information system in germany does not capture information related to the health status of and healthcare provision to asylum seekers this means that basically no information on this population group can be derived from routine health monitoring sources data protection issues further hamper the possibility to assess eg health problems or access to and utilization of health services on a routine basis despite the longstanding public health relevance of this topic there is yet no systematic overview of the research landscape on the health status of and healthcare provision to asylum seekers in germany the lack of overview of this field makes it difficult to judge upon the range scope and quality of research conducted it also limits the possibility to develop the prospects of a future research agenda a pertinent example can be found in the literature on mental health of asylum seekers of the international systematic reviews on the prevalence of mental health disorders among asylum seekers known to the authors 45 none list any studies conducted in germany it remains unclear whether this is due to a general lack of studies from germany or due to the specific inclusion criteria of respective reviews further examples can be found in analytical studies conducted in other countries which highlight the importance of potentially modifiable postmigration determinants affecting the health status of asylum seekers in their host countries a longitudinal study conducted in the netherlands has shown that frequent relocations between asylum seeker centers increase the risk for mental distress among asylumseeking children 6 a metaanalysis of primary studies reporting psychopathologies among asylum seekers has found that worse mental health is associated with institutional accommodation and restricted economic opportunities in the host country 7 others have more broadly assessed the relation between need and utilization of health services among asylum seekers in the united kingdoms 8 however it remains unclear if similar questions have been addressed in germany at all and if yes to which extent given the crucial role of research in illuminating health disparities an overview of the scientific literature in the german context is highly needed to consolidate knowledge avoid scientific redundance and identify research gaps with respect to this marginalized population the objectives of this study are 1 to systematically review examine and map the range scope and quality of research on the health status of and healthcare provision to asylum seekers in germany 2 to synthesize knowledge from empirical studies on the health status of and healthcare provision to asylum seekers germany 3 to identify evidence gaps and areas for future research review questions the following review questions will be addressed 1 what is the range scope and quality of research on asylum seekers health status and healthcare situation in germany 2 what is known from these studies about the health status of and healthcare provision to asylum seekers in germany 3 what are the evidence gaps with respect to the health status of and healthcare provision to asylum seekers in germany methodsdesign study design this systematic review will apply both aggregative and configurative approaches 9 aggregative reviews are seeking evidence to inform decisions and make statements by collecting empirical data the interest of configurative reviews is more in examining the complexity and range of different concepts than in seeking a single correct answer 9 to examine the variation in and complexity of different research approaches we will mainly use configurative methods the information attained from included studies will serve to consolidate existing concepts and develop new insights about the health situation of asylum seekers the review contains aggregative elements for analyzing collected data in a realist synthesis which answers objective 2 an evidence map will be created with the aim of describing the research field and to structure and interpret the following synthesis the development of the protocol was informed and guided by the eppicentre guidelines 10 the cochrane guidelines for systematic reviews of health promotion and public health interventions 11 the crds guidance for undertaking reviews in health care 12 and systematic reviews in the social sciences a practical guide 13 the report of our systematic review will adhere to prismaequity 2012 extension reporting guidelines for systematic reviews with a focus on health equity 14 as far as applicable to give special consideration to the aspect of equity search method for identification of studies in the first step we will search in databases for relevant articles fulfilling predefined inclusion criteria following that we will perform a screening of the citing and cited references of all included articles strategy 1 search databases we developed the search strategy according to cochrane handbook for systematic reviews of interventions 15 the following electronic databases will be searched for studies and reviews bibliographic databases ○ pubmedmedline ○ isi web of science ○ international bibliography of social sciences ○ sociological abstracts ○ social sciences citation index ○ worldwide political science abstracts ○ cinahl ○ sowiport ○ assia ○ medpilot ○ deutsche nationalbibliothek ○ cochrane library without limitation to specific databases dissertation and theses databases the search terms and and german are searched for in the articles title abstract and key words for databases providing publications in german language we will use the search terms and gesundheit further searches will be conducted by using web search engines to include grey literature articles which give essential information but are not published in journals to limit the number of hits to the relevant ones we will search for und und and and and german the google search will be conducted in three steps first screening all hits second we will search for pdf files only followed by a search for doc files only additional searches will be performed on websites of ngos to increase the sensitivity of our search strategy an overview of the final search term combinations which will be applied for searching each database is available in additional file 1 strategy 2 searching in the selected articles we will view the reference lists of all included publications moreover we will use backward and forward citations for web of knowledge for all publications included at the end of the screening process strategy 3 contacting experts individuals and nongovernmental organizations we will contact experts authors of identified studies and nongovernmental organizations to identify grey literature selection of studieseligibility criteria broadly spoken all empirical studies that use a sample of asylum seekers will be included regardless of the research question as long as they report a health outcome or an outcome measure related to healthcare provision inclusion criteria more specifically we will include studies which fulfill the following criteria type of population refugees and asylum seekers types of studies we will include all published empirical materials including qualitative studies and quantitative studies as well as mixedmethods studies unpublished material will only feed into the review if the review team is granted full access to the reports since many studies might not be analytical in nature we explicitly consider descriptive surveys for inclusion provided that sufficient information on data collection and analysis is provided types of articles original articles and review articles including systematic and narrative reviews authors of relevant conference abstracts will be contacted for full research reports if available they will be included in the review type of outcome measure ○ health including all criteria of who definition 16 physical mental and social wellbeing ○ all aspects of healthcare provision geographical area studies conducted in germany or studies giving account of asylum seekers experiences in germany date of publication initial search without limitation mapping and synthesis will be performed by distinguishing between studies pre1993 and post1993 due to major changes in legislation in 1993 exclusion criteria type of population migrants without clear reference to asylum seeker statusrefugee status types of articles commentaries discussion papers journalistic interviews policy reports books conference proceedings abstracts type of outcome measure studies assessing social situation without clear link to health understood as physical mental and social wellbeing geographical area studies conducted on asylum seekers outside germany andor where the primary focus is not their situation while they resided in germany articles not published in german or english screening process the screening process will be conducted in two steps screening titles and abstracts 2 screening full texts title and abstract screening two reviewers will independently screen 10 of the articles by title and abstract resulting from the search process and assess them for inclusion using the a priori defined criteria if necessary inclusion and exclusion criteria will be redefined based on this initial screening before screening all articles subsequently all article titles and abstract will be screened in duplicate using the inclusionexclusion criteria eligibility for inclusion from both the initial and subsequent screening process will be recorded in an excel fileendnote database discrepancies in judgements on eligibility will be solved by discussion in the review team if discrepancies in judgement on eligibility exist in absence of clear exclusion criteria we will obtain all publications as full text that are deemed relevant by at least one reviewer full text screening we will obtain the full text of all the references included after title and abstract screening all files will be incorporated to a bibliographic database two reviewers will independently read the full text of the previously selected articles and assess eligibility for inclusion disagreements will be discussed in the review team and only references judged as eligible by all will be included screening of citations finally for the publications included after the screening process we will review the references which are cited by and cite our relevant articles furthermore we will screen all articles received by experts authors of identified studies and nongovernmental organizations they will also be screened by using the stages described above with the same inclusion and exclusion criteria sensitivity and specificity of search strategy and selection process we will assess the specificity and sensitivity using a test set of articles at hand of the authors prior to conducting the systematic review data extraction and critical appraisal data extraction and critical appraisal will be conducted simultaneously and be piloted against a random sample of the included articles by two reviewers data extraction we have designed preliminary data extraction forms based on the strobe and qorec checklists for quantitative and qualitative studies respectively adapted to the specific characteristics of this review the data extraction forms include the following items generic bibliographic information study characteristics study objectivesresearch questions population and context characteristics health condition andor healthcare provision domain analyzed or explored for quantitative studies exposures and covariables on individual andor contextual level as well as measures of frequencyassociation for the analyzed outcomes for qualitative studies major themesminor themes as reported results of the critical appraisal further details on the type of data we seek to extract from quantitativequalitative studies are provided in additional file 3 and additional file 4 the preliminary data extraction form for reviews can be found in additional file 5 modifications in the data extraction forms are expected after the pilot study given the broad research questions an iterative approach in developing and refining the data extraction form will be more adequate than a predefined fixed approach all the reviewers will participate in the data extraction of the selected articles 50 will be extracted by am the other 50 will be extracted by cs all articles will be checked vice versa and will be checked by random sampling by sj and kb disagreement will be resolved by discussion until consensus is reached all extracted data will be recorded in a transparent and systematic way which will be detailed in the review report critical appraisal different types of included studies need to be critically appraised with appropriate appraisal tools for the study design critical appraisal of selected quantitative studies will be conducted by means of the quality assessment tool for quantitative studies of the effective public health practice project mixedmethods studies will be judged by the mcgill mixedmethods appraisal tool for mixedmethods studies 8 the quality of reviews will be appraised using the amstar tool a validated 11item tool to assess the quality of systematic reviews 17 the tool will also be applied to nonsystematic reviews in order to assess the quality of included reviews against the gold standard of a systematic review nonapplicable items will not be weighted in order to avoid undue judgements on the quality of nonsystematic reviews raised by the nonapplicability of amstar items there is currently no consensus among qualitative researchers on the role of quality criteria and how they should be applied and there is ongoing debate about how study quality should be assessed for the purposes of systematic reviews 1318 prior to the review process a selective literature review has been conducted by the review team to identify the most suitable assessment tool for the quality appraisal of qualitative studies which will be included in our systematic review we followed the cochrane guidance for critical appraisal of qualitative research 1920 and agreed on the use of the critical appraisal skills programme for qualitative studies the reasons for applying casp are as follows it is widely used in similar reviews and recommended by cochrane guidance and the guidance of the center for reviews and dissemination it contains only 10 items for rapid evaluation it is suitable for different types of qualitative studies the critical appraisal process will not lead to exclusion of papers but rather serves as one of several other criteria to evaluate the body of evidence analysis of findings summary table one or more tables will be drawn up containing condensed information from the data extraction forms evidence map in the next step we will create a thematic and conceptual evidence map to illustrate the research landscape and identify research gaps to this end all included articles will be grouped and categorized by year of data collection research design and the analyzed health conditions andor healthcare domains in its descriptive way this map will address objectives 1 and 3 by providing a systematic description of available research the body of evidence will be evaluated by the following criteria the number of studies analyzing the same outcome or exploring the same topic overall quality and risk of bias credibility external validity saturation and transferability and consistency of findings across studies any modifications to this protocol will be made transparent and documented in the final review report evidence synthesis as our review question dictates the inclusion of many different research designs we will follow the recommendation to use a primarily narrative synthesis 21 to answer review question 2 despite the absence of procedures and standards the narrative synthesis allows flexibility and coping with large evidence base comprising diverse evidence types beginning with a quantitative analysis the included studies will be organized and presented in logical categories by study design we decided to apply a multilevel approach where quantitative evidence and qualitative evidence are synthesized as separate streams and the product of each synthesis is then combined if possible we will conduct a metaanalysis to summarize the findings of quantitative studies which analyze the same outcome as there are no standard approaches for the synthesis of qualitative data 13 we will combine a descriptive synthesis with a narrative elaboration of the patterns identified in qualitative studies narrative descriptions of each included article will provide a short clear summary of information on a range of process and outcome measures we will then combine separate elements to form a coherent whole a synthesized finding of qualitative research in the third synthesis we will integrate the findings of all primary studies taking into account variations in study design context and study quality this final configuration of synthesized findings will be a summary of knowledge about the health status of and healthcare provision to asylum seekers in germany as generated by empirical studies the overall design and process of this review is shown in figure 1 discussion this systematic review will provide the first evidence map and synthesis of available research findings on the health status of and healthcare provision to asylum seekers in germany such an overview is paramount to avoid redundant research identify knowledge gaps and consolidate existing knowledge we hope that the results will help guide future research on this topic and help shape a future research agenda to improve the health and health care of this marginalized population the results of our review could also be used to identify potential targets and areas for interventions aimed at treating or preventing certain conditions or mitigating the effects of individual or structural risk factors on asylum seekers health the strength of this anticipated review lies in a clear protocol with eligibility criteria a transparent and systematic search strategy and advanced approaches for screening extracting and appraising the available research the review follows clear steps for the analysis of findings by evidence mapping and narrative description of results we include both german and english quantitative and qualitative studies published both before and after 1993 when asylum policy changes were made thus we ensure to cover a wide range of relevant information as such this review will provide a detailed and reliable overview of the field for future research and will identify evidence gaps which require further exploration we further anticipate that information gained by the review will help health professionals and policy makers to better understand needs in healthcare provision which need to be addressed to ensure that our results will be accessible to policy makers healthcare providers and researchers and promote further discussion we will publish this review in an open access journal and disseminate the findings via conferences civil society organizations and academic institutions additional files additional file 1 search strategy for databases this shows the searched databases with the according search term additional file 2 sensitivity and specificity lists of all references which serve as a test set to assess sensitivity and specificity of the prior conducted screening competing interests the authors declare that they have no competing interests authors contributions kb conceived and designed the study contributed to the overall review design and preparation of the review protocol developed the search strategy and prepared the draft am and cs contributed to the study design and conception drafted the review protocol and led the development of the search strategy data extraction and analysis of findings sj provided important inputs to the study design and revised the protocol all authors read and approved the final the manuscript

background there are more than 100000 asylum seekers registered in germany who are granted limited access to health services this study aims to provide a systematic overview of the empirical literature on the health status of and healthcare provision to asylum seekers in germany in order to consolidate knowledge avoid scientific redundance and identify research gaps methodsdesign a systematic review and evidence mapping of empirical literature on the health status of and healthcare provision to asylum seekers in germany will be performed we will apply a threetiered search strategy 1 search in databases pubmedmedline web of science ibss sociological abstracts worldwide political science abstracts cinahl sowiport social sciences citation index assia medpilot dnb dissertation and theses databases and the internet google 2 screening references of included studies 3 contacting authors and civil society organizations for grey literature included will be studies which report quantitative andor qualitative data or review articles on asylum seekers in germany published in german or english language outcome measures will include physical mental or social wellbeing and all aspects of healthcare provision access availability affordability and quality search results will be screened for eligibility by screening titles abstracts and full texts data extraction comprises information on study characteristics research aims and domains of health or healthcare services analyzed the quality of studies will be appraised and documented by appropriate assessment tools a descriptive evidence map will be drawn by categorizing all included articles by research design and the health conditions andor domains of healthcare provision analyzed the body of evidence will be evaluated and a narrative evidence synthesis will be performed by means of a multilevel approach whereby quantitative and qualitative evidence are analyzed as separate streams and the product of each stream is configured in a final summary discussion this systematic review will provide an evidence map and synthesis of available research findings on the health status of and healthcare provision to asylum seekers in germany in anticipation of identifying areas which are amenable to healthcare interventions deserve immediate action or further exploration this review will be of major importance for policymakers healthcare providers as well as researchers

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enduring inequalities in mental healthcare exist between uk minority ethnic and white british groups 1 individuals from minority ethnic groups are more likely to be detained under the mental health act and receive restrictive interventions 2 failure to discuss cultural or religious factors or provide accessible information for informed consent on treatment contributes to poor experiences of care those poor experiences together with cultural stigma and fear of being discriminated against generate barriers to access 3 during the covid19 pandemic people from minority ethnic groups experienced a disproportionately high impact on their mental health 4 5 6 but the reasons for this were not fully clarified previous literature has attributed the lack of progress in addressing ethnic inequalities in mental healthcare 7 to inadequate understanding of the key drivers of inequalities and in particular the role of societal factors such as racism 8 the covid19 pandemic and resulting service changes offered an opportunity to explore which serviceand societallevel factors might be involved in driving inequalities the aim of this study was to develop a multilevel understanding of how ethnic inequalities are created and sustained in mental healthcare drawing together the complexity of experiences from diverse ethnic and stakeholder backgrounds 910 in the current study we focus on barriers to mental healthcare for solutions to these barriers the reader is directed to our companion study on improving mental healthcare through codesigned action plans 11 method this semistructured interview study was part of a multisite experiencebased codesign project to develop actions for improving access and experience of mental healthcare for people from minority ethnic groups 11 study sites included four different geographical areas covered by national health service mental health trusts areas were selected to reflect diversity across england including differences in urbanicityrurality deprivation and ethnic composition topic guides covered stakeholder perspectives on barriers to mental healthcare for minority ethnic patients prior to the covid19 pandemic and experiences of mental healthcare during the covid19 pandemic four trained researchers conducted onetointerviews which were audiorecorded and transcribed verbatim patients and carers were given a £20 voucher for participating interviews were conducted between 8 july 2021 and 15 july 2022 following the launch of the covid19 vaccination programme in december 2020 and the final uk national lockdown in march 2021 owing to continuing local restrictions and health and safety concerns most interviews were conducted remotely the team worked closely with local clinical studies officers to ensure that participants without internet access were offered an inperson or telephone interview researchers provided additional support to participants who had internet access but were unsure how to join online meetings patient and public involvement full details on ppi roles and responsibilities are given in supplementary table 1 available at 202411 for the lived experience advisory panel included members from each study site the panel met online six times to provide input on ethical recruitment procedural and acceptability issues in addition to views on emerging research findings two peer researchers were included in the core research team and contributed to all aspects of the study including recruitment interviewing cofacilitating focus groups and workshops analysis and dissemination use of terminology per government guidelines 13 we selected the term minority ethnic accepting that preferences in terminology vary that minority ethnic is not a homogeneous group and that we would not be able to include participants from all ethnicities included under this umbrella term ethics statement the authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the helsinki declaration of 1975 as revised in 2008 all procedures involving human subjectspatients were approved by the health research authority and the health and care research wales ref 21wa0181 analysis the six stages of the framework analysis 14 are described in supplementary table 2 following development of the initial codebook by the core research team cw conducted the analysis in nvivo 12 pro for windows 15 we selected the framework approach as it facilitates analysis of data from a large number of participants in a rigorous transparent and logical process 16 and enabled comparison of responses from different stakeholders and areas using a framework matrix 17 using the constant comparative method we were able to make comparisons across cases to refine each theme while tracking and grounding findings and interpretations within the raw data 17 during the framework process we systematically reduced data from emergent themes to mapped impacts and outcomes the final mapped themes and subthemes were used to populate the logic model charting how covid19 impacts exacerbated prepandemic barriers and their outcomes the main themes and logic model were reviewed by the research team results using themes and subthemes derived from our framework analysis we mapped out a logic model to summarise how ethnic inequalities in mental healthcare were affected by the covid19 pandemic from left to right the model delineates prepandemic barriers moderating effects of the pandemic and intermediate and longterm outcomes as indicated in the model hypothesised interrelationships were complex and bidirectional some exacerbating and others reducing barriers barriers to access and mental healthcare prior to the covid19 pandemic prepandemic barriers are summarised in fig 1 supplementary table 3 presents comparative quotations from patientscarers and professionals supplementary table 5 presents comparative quotations from the four different sites individuallevel barriers included mistrust of mental health services supernatural illness attributions lack of mental health literacy and cultural stigma patientscarers described mistrust in services which was attributed to previous negative experiences andor concerns of being locked away or overmedicated professionals similarly noted a mistrust of mental health services within roma asylumseeking south asian and black communities which prevented people from accessing services supernatural illness attributions were commonly reported in south asian and black african communities by professionals and patients carers supernatural beliefs led to a search for other answers through seeking alternative remedies patientscarers described a lack of awareness or understanding of mental ill health which led to selfmedicating and delayed helpseeking professionals noted a lack of mental health literacy in chinese south asian and black communities reducing likelihood that they would access mental health services cultural stigma attached to mental illness and the use of mental health services was discussed across all sites and participant types and was considered a powerful deterrent to seeking mental healthcare in south asian black african roma and orthodox jewish communities servicelevel barriers included dominance of a monocultural model racial prejudice and discrimination negative clinical encounters nhs landscape superficial attempts to reduce inequalities and reluctance to acknowledge ethnicity and racism in mental healthcare these barriers led to poor communication disengagement from services and alienation patientscarers and professionals noted the dominance of a monocultural model participants reported that mental health services lacked inclusivity in terms of staff diversity cultural understandings materials provisions and treatment options linguistic and conceptual communication barriers were common some professionals from site 2 felt that they worked in very diverse teams which facilitated communication and understanding patientscarers and professionals recalled examples of racial prejudice stereotyping and discrimination patients recollected being restrained a bit too often carers recalled loved ones being unfairly judged or treated and quickly diagnosed misdiagnosed negative verbal interactions were experienced as life changing and included snapping for no reason microaggressions and gaslighting some patientscarers did not report any experiences of prejudice or racism negative clinical encounters were a recurring theme in patient carer interviews although not explicitly linked to ethnicity they were considered an additional barrier to helpseeking and engagement experiences included dismissive insensitive and patronising attitudes poor communication and feelings of being judged patientscarers noted that nhs services were oversubscribed thus staff do not have time to probe and that once youve had a few years of psychology your quotas gone professionals concurred that services were underresourced making the provision of culturally appropriate mental healthcare more challenging participants noted superficial attempts at tackling inequalities and a reluctance to acknowledge ethnicity racism and mental illness patients felt there was a lot of talk but no action and professionals noted that nhs initiatives were often a tick box exercise professionals felt that responsibilities were placed on minority ethnic staff to solve the problems of the system and boost the corporate image patients felt that racism within services was not acknowledged and that they were unable to speak openly about their racial struggles for fear of being misunderstood or getting shut down professionals noted a lot of defensiveness and fear of getting it wrong especially among white professionals contributing to the maintenance of issues about racism and discrimination societallevel barriers included socioeconomic inequalities and systemic racism patients felt that their economic status contributed to judgement and discrimination within services and professionals noted the role of financial disadvantage in the development and treatment of mental illness patientscarers reflected on how racism in society had had an impact on their perceptions and behaviour within services professionals felt that structural racism could lead to a cycle of anxiety or avoidance of services impacts of the covid19 pandemic on mental health services and patients impacts of the covid19 pandemic are summarised in fig 1 ripple effects included anger and disillusionment scepticism and distrust isolation exacerbation of communication difficulties and racism and division supplementary table 4 presents illustrative quotations by participant type supplementary table 6 presents comparable quotations by site in the quotations presented below participant details include stakeholder type participant number ethnicity and site reduction in access and regularity of mental health services reductions in accessibility and regularity of mental health services were described by patientscarers and professionals patientscarers noted that services went completely silent and were less responsive creating an additional barrier to access although some patients viewed the pandemic as just another time of something new i had to adapt to professionals noted that covid19 had an impact on all patients but became more noticeable for some people from minority ethnic communities because there was already a lack of resources for them professionals described increased difficulties in obtaining interpreters which exacerbated communication barriers for patients who could not speak english as services became less proactive ethnic minority patients who were unable to advocate for themselves were more likely to be missed and forgotten coming back to communication in the way that we keep in touch with people and how people access us i think it … must have had a disproportionate effect on people from minority ethnic communitiesbecause were being less persistent in the way that we access people and support people remote service delivery most patientscarers from minority ethnic groups preferred facetoface interactions however some liked the convenience of remote consultations professionals noted that remote consultations could be more convenient and costeffective for some patients and had led to a reduction in missed appointments however others highlighted the digital divide and observed that remote consultations were not a productive way to develop trust with patients from minority ethnic groups especially those who struggle with english this has been an issue during the pandemic because if were doing for example video consultations its very difficult to include interpreters and often i think patients may lose patience or some may lose patience to set up these video calls so i would say that maybe with this group of people who are not english speakers communication can be quite challenging heightened risk and expectations on minority ethnic staff patientscarers described increased pressure on mental health professionals but were not aware of differential impacts on minority ethnic staff professionals from minority ethnic backgrounds described being hyperanxious as they felt at greater risk from covid19 professionals noted that minority ethnic staff were expected to work in red zones while others just stepped back despite the increased risk this has happened in the nhs for a really long time asking black and brown members of staff to do the jobs that people didnt really want to do or asking them to do overtime at one point the group of people who died relatively was the filipino nurses because in philippine culture theres a rule around saying no when people need support they were asking these filipino nurses to work 1216hour shifts six days a week because they knew they wouldnt say no this will have a lasting impact closure of community organisations patients were disappointed when community groups closed as they were unable to go to their places of worship or connect with their communities professionals noted that the closure of community organisations had a disproportionate impact on people from minority ethnic groups especially those not confident with speaking english or asylum seekers who often relied on thirdsector organisations for culturally appropriate care so i think covid overall has impacted everybody but i think maybe in terms of knowing where to go for support i wonder if its impacted people from ethnic minorities especially if they dont speak english or are not confident with speaking english are isolated or are asylum seekers i think it would be a real struggle because most culturally appropriate services we use are thirdsector charities so during covid they all stopped professionals noted a vicious dropout of minority groups who backed off following the shutdown of community organisations were picking up bengali women and somali men but thats just a small example of … lots of other minority groups who are kind of backing off because they get to a stage where they need that support and they normally get it from the community to be honest with you and theyre not theyre not getting it from their local community not as much media scaremongering and stereotyping patientscarers and professionals commented on scaremongering in the news including an avalanche of statistic figures that made you have anxiety patients and professionals noted that the first lockdown coincided with media coverage of george floyds murder which felt really e ntwined further increasing anxiety and fear as it was felt that well be the last to be looked after professionals were concerned that media coverage of the pandemic was characterised by sweeping statements and divisive reporting blaming black and brown people subsequently stoking racism and misinformation and preventing people from socialising and engaging with services for fear of persecution positive and negative developments from the covid19 pandemic positive and negative developments are summarised in fig 1 positive developments are hypothesised to reduce preexisting barriers and outcomes whereas negative developments are hypothesised to exacerbate existing barriers illustrative quotations are given in supplementary tables 4 and6 anger and disillusionment patientscarers expressed anger and frustration at not being able to access services and the lack of continuity of care during the pandemic professionals noted disillusionment in ethnic minority communities who didnt have the fight and anger as inequalities were brought to the foreground i think there is a sense that some communities particularly i think the black community the black caribbean community feel quite left behind and so there was quite a lot of anger and that led to some psychological feelings of isolation and of loss scepticism and distrust patients expressed scepticism during the pandemic including disbelief of news reports and reservations about the covid19 vaccinations professionals noted a distrust in nhs professionals and an antiauthority feeling especially among ethnic minority groups it was felt that it will take a long time before people can trust health systems again and a lot of our clients obviously who arent from this country believe what they read on facebook and then thats it they go with that i think that has put a big gap between us especially a wall up for their own safety more than anything else and i think were the last service that they want to engage with empowerment patients from site 2 experienced empowerment during the pandemic including a motivation to get fit and eat well they found solace in creative pursuits producing the best poems ive ever written and concentrating on the garden making new things but its only like recently like during covid i decided to act upon my side effects because i thought to myself im not… thank god you know im still living even during covid i havent had any covid reaction and i thought im going to tackle my side effects because im stable and i want to improve my flow… professionals marvelled at the resilience and creativity shown by some patients causing them to reflect on the system of care they provided flexible approach to service provision the pandemic brought about new ways of working improving efficiency and convenience for some patients from minority ethnic groups professionals felt that changes made during the pandemic had given them new ideas for service provision including providing a hybrid model creative approaches such as email therapy and immersive exercises to provide a more diverse way of thinking of viewing the world spotlight on inequalities all stakeholder types saw the pandemic as a wakeup call bringing to attention medical racism and disparity professionals observed more open conversations within their nhs trust and were prompted to engage in transformation work to reduce inequalities in terms of after what changed it also brought to the forefront the disparity now everything is moving towards digitisation and it so most of our clients we realisedthey have phones but theyre not smartphones so we have been able to go and argue for more money as part of this transformation we are trying to do discussion our study showed that the pandemic disproportionally affected minority ethnic patients in england through the exacerbation of preexisting barriers and their outcomes as services became less proactive patients who could not advocate for themselves were less likely to be able to access services increasing the likelihood of avoidance or delayed helpseeking remote service delivery exacerbated communication difficulties and excluded those without access to smart technologies the closure of community organisations reduced access to culturally appropriate support increasing withdrawal and isolation in minority ethnic groups media scaremongering and scapegoating contributed to disengagement and isolation by stoking blame and division and increasing mistrust in services as reported by healthcare staff in previous studies 1819 mental health professionals felt that ethnic minority staff were under greater duress during the pandemic barriers to mental healthcare are maintained by superficial attempts to tackle inequalities a reluctance to acknowledge ethnicity and racism and structural factors highlighting the need for a multilevel approach to reducing inequalities although patients carers and professionals viewpoints largely converged negative clinical encounters were a more prominent concern for patientscarers who described how dismissive or judgemental interactions led to distress and disengagement from services moving forward safe and equitable personcentred care should include full consideration of the lived experience of minority ethnic patients 8 including acknowledgement of the intersection between ethnicity racism and mental ill health 20 views on barriers and covid19 impacts were remarkably similar across all four sites indicating that barriers are endemic in england however there were some indications that area 2 is leading the way in transformational work with higher levels of team diversity and patient empowerment as the country recovers from the pandemic it will be key to recognise the importance of thirdsector organisations in providing culturally appropriate mental healthcare 8 including how these services can be integrated into the reshaping of the care system 21 the onus is on services to promote equity over simplistic views of equality ensuring representation of marginalised groups in nhs services at all levels 18 positive developments observed during the pandemic could be leveraged including a prioritisation of empowering recoveryoriented models 22 incorporating nature and creative therapies as antioppressive approaches 823 adopting a hybrid model to service delivery might help improve access for some minority ethnic patients 24 including those concerned about the stigma associated with visiting services the heightened focus on ethnic inequalities as a result of the pandemic might help services argue for more resources and encourage open conversations about racism 25 ethnicity and intersections with mental ill health limitations we used a logic model to organise and present our qualitative findings this enabled us to conceptualise prepandemic barriers to access and care and potential covid19 impacts that might have moderated these barriers and their outcomes however it should be noted that this was not a full logic model analysis rather we used the logic model to allow a depiction of the themes and subthemes that emerged from our framework analysis ie we used an inductive approach to fully capture our stakeholders views and experiences rather than imposing an a priori theoretical framework on the analysis future research might aim to elucidate the mechanisms underpinning the interrelationships between impacts and barriersoutcomes to inform innovations in equitydriven mental healthcare our purposive sampling approach might have led to the exclusion of some groups eg those with less severe mental illness who did not use secondary care services most patientcarer participants identified as having black or south asian heritage and were recruited in urban areas the extent to which findings are generalisable to other ethnic backgrounds or to rural areas is unclear despite our best efforts we were unable to recruit nonenglish speaking participants a group that professionals indicated were especially affected by the impacts of the pandemic most interviews were conducted virtually this might have hindered some conversations but also increased access and convenience for some participants we were unable to include all impacts of the covid19 pandemic in our analysis owing to space limitations future directions the covid19 pandemic appears to have exacerbated ethnic inequalities in mental healthcare and more broadly some positive developments were also reported which need to be actively pursued by services including a focus on recoveryoriented treatment options and equity however the reduction of community support through nhs and thirdsector services has resulted in experiences of discrimination and poor communication with services fuelling alienation prejudice and mistrust what happened during the covid19 pandemic may have a longlasting impact on the access and engagement of people within minority ethnic groups particularly those who are most vulnerable and marginalised to offset or reduce negative consequences the nhs and integrated care partnerships will need to address them promptly and radically this could be helped by learning from patients voices to further transformative models for community care data availability requests for the data that support the findings of this study should be directed to the corresponding author dg who will discuss them with the lead institution coventry and warwickshire partnership nhs trust supplementary material supplementary material is available online at declaration of interest kb was editorinchief of the bjpsych when the original submission was made and did not take part in the review or decisionmaking process of this paper community mental healthcare and minority ethnic groups

enduring ethnic inequalities exist in mental healthcare the covid19 pandemic has widened theseto explore stakeholder perspectives on how the covid19 pandemic has increased ethnic inequalities in mental healthcarea qualitative interview study of four areas in england with 34 patients 15 carers and 39 mental health professionals from national health service nhs and community organisations july 2021 to july 2022 framework analysis was used to develop a logic model of interrelationships between prepandemic barriers and covid19 impactsimpacts were largely similar across sites with some small variations eg positive service impacts of higher ethnic diversity in area 2 prepandemic barriers at individual level included mistrust and thus avoidance of services and at a service level included the dominance of a monocultural model leading to poor communication disengagement and alienation during the pandemic remote service delivery closure of community organisations and media scapegoating exacerbated existing barriers by worsening alienation and communication barriers fuelling prejudice and division and increasing mistrust in services some minority ethnic patients reported positive developments experiencing empowerment through selfdetermination and creative activitiesduring the covid19 pandemic some patients showed resilience and developed adaptations that could be nurtured by services however there has been a reduction in the availability of groupspecific nhs and thirdsector services in the community exacerbating preexisting barriers as these developments are likely to have longterm consequences for minority ethnic groups engagement with mental healthcare they need to be addressed as a priority by the nhs and its partners

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introduction general practitioner led communitybased hospitals provide hospital care mainly in sparsely populated rural areas in many countries 1 2 the cairns consensus statement 3 defines rural generalist medicine by the broad scope of medical care a rural doctor provides this includes primary care hospital inpatient care emergency care and a population health approach to provide services responsive to community needs both locally and at a distance in new zealand hospitals are categorised by size and by service provided six levels along a continuum from level 1 to level 6 4 there are 33 rural hospitals in nz they are all categorised as small and with service levels 13 based on medical coverage and resources 5 rhs have evolved in response to local needs and economic circumstances resulting in a variety of sizes services and ownership modelsa mix of public hospitals run by district health boards and community trusts 6 7 the medical and nursing care provided in rhs cover many vocational areas of clinical practice 8 as do rural community hospitals in other countries 1 traditionally rh medical care in nz has been provided by local rural gps and medical officer of specialist scale rhs strengths and limitations of this study ⇒ in this study both interviewer and interviewees had professional knowledge of the topic studied thereby taking advantage of the researcher as an instrument of the research ⇒ the diversity of sizes and services in the rural hospitals visited reflected different aspects of rural hospital care ⇒ qualitative content analysis was considered suitable as it is a methodologically flexible approach enabling interactive changes to the interview schedule as new information is gathered furthermore this approach enables findings relevant to a specific problemissue to be documented ⇒ male and female doctors with varying clinical experience and of different ethnic origin participated however no māori doctors were interviewed open access are defined as a hospital staffed by suitably trained and experienced generalists who take full clinical responsibility for a wide range of clinical presentations… 6 rural hospital medicine was recognised as a new scope of practice in 2008 and specialitytraining programmes adapted for the needs of rh doctors were implemented 5 9 rh doctors would meet the cairns consensus statements definition in their work at the rh but approximately half of the workforce work full time at the rh and not as gps 5 the otago rural hospitals study found that rh patients were older than those admitted to larger hospitals 10 this is consistent with studies on similar models of rh care in other countries 11 12 13 14 these studies indicate that some patient groups mainly elderly patients with exacerbation of chronic diseases and infections could be offered different levels of hospital care depending on the presence of an rh in their community a recent nz policy document emphasises an estimated increase in hospital bed usage in the coming decades due to an ageing population and states that the complexity of hospital cases will increase due to multimorbidity and frailty 4 furthermore new models of care are looking to provide more care in communities closer to where people live with earlier discharges of patients from general hospitals to rhs for step down care adding further pressure on rural healthcare systems 4 15 rhs provide hospital care for patient groups elsewhere treated at general hospitals and that are predicted to constitute an increasing proportion of future rural hospitalisations rh medicine doctors will therefore be responsible for the care of an increasing number of complex patients little is known about rh doctors experiences of providing care in nz 16 it is therefore important to explore how these doctors view their role and that of their rhs in their community in the context of the wider nz healthcare system aim the aim of this study was to explore rh doctors experiences of providing care in rhs in southern nz methods study setting nzs south island has a population of 11 million 17 dispersed over a geographical area of 150 000 square kilometres 18 secondary and tertiary hospital care is provided to the population mainly by the general hospitals in nelson christchurch dunedin and invercargill these hospitals also serve as supporting base hospitals for their associated rhs of which 12 are located in south island the study took place in rural parts of otago canterbury and west coast regions in the south island of nz design and sampling the study employed a qualitative exploratory design 19 a purposive sampling approach was used to invite rh doctors to the study aiming to include men and women with different level of experience and of differing ethnic origin from a variety of rhs in south island it was initially estimated that the study needed 15 participants with above variation participants were recruited using email lists provided by the managing directors of the south island rhs data collection semistructured facetoface interviews were conducted by the phd student mh at the doctors work or in another undisturbed place of their choosing between october and november 2018 using an interview guide previously used in a swedish interview study and modified for use in english and to the nz context by the nz collaborators the interview technique included openended and probing questions with more specified questions used to orient the discussion towards areas of interest for the study interviews lasted on average 1 hour all interviews were digitally recorded and transcribed transcripts were shared with participants for accuracy checking data analysis the interviews were analysed according to qualitative content analysis using an inductive approach 20 21 transcripts were read through several times to get a sense of the whole the analysis sought to identify meaning units which were condensed and labelled with descriptive codes codes were compared with identify similarities and differences and then sorted into categories according to content during the analysis process the codes and categories were discussed in the research group to seek consensus and subthemes and themes formulated 22 descriptions of subthemes including representative quotes from the doctors are presented in the results section participant doctors were numbered 116 we used the consolidated criteria for reporting qualitative research 23 to structure reporting of study findings patient and public involvement no patients or the public were involved in the design of this study results fifty applying a holistic perspective to care the first theme applying a holistic perspective to care encapsulates two subthemes providing care close to home and family and seeing the whole patient providing care close to home and family doctors discussed three aspects of providing hospital care close to home and family the practical the emotional and the spiritual the importance of these aspects made it an ethical as much as a medical issue to keep a patient or refer them to the nearest base hospital practical aspects included the ease for patients with the care close to home as well as for relatives to come and visit compared with having to travel to a base hospital for relatives on a lowincome travel costs could be an issue if your father gets admitted to dunedin what do you do do you take two weeks off work and stay close to your father or do you drive up and down twice each day before and after work it is impractical for the family but if it is here they could just pop around for five minutes and have a chat and go home go back to work much better for the patients who get to see their family members more doctors described rh rooms for palliative end of life care with the possibility for family members to stay overnight often with kitchenettes alternatively these rooms could be used for children and their parents in rhs that accept paediatric inpatient care emotional aspects were considered essential for the local populations feelings of safety and wellbeing linked to the personal connection and homeliness of the facilities doctors perceived feelings of pride over the service the hospital provided to the local population and people also feel very proud of the hospital both the people that work here and the people who live here because they know that it is a hospital that understands them and understands the community they live in and provides the highest standard of care in a very effective and efficient manner european 7 other european 2 asian 1 the analysis identified three themes which are summarised in table 3 along with their associated subthemes and categories open access spiritual aspects of rhs close to home was particularly prominent when discussing endoflife care for māori patients dying close to home was described as a very important spiritual aspect for māori patients as none of the participants were māori these conversations led participants to reflect on their shortcomings in relation to their understanding of māori tikanga and they recognised that there was room for improvement in the rh care of māori patients seeing the whole patient doctors described the importance of seeing the whole patient particularly for patients with multimorbidity or palliative needs these aspects were brought out when discussing medical generalist perspective holistic perspective and continuity of care medical generalist perspective all rh doctors claimed to have a generalist perspective in the care of their inpatients that is a medically wider role compared to that of base hospital specialists it was stated to be difficult for a generalist to turn down patients and say that the patients problems were not within the scope of their competence leading to a preparedness to do unfamiliar tasks in a way other hospital specialist doctors would restrict themselves from doing not being in their area of expertise this aspect of the rh generalist role was described by the doctors as we specialize in everything that comes in through the door rh doctors problematised that deeper specialisation leads to the loss of a broad perspective claiming that hospital specialists more often need to consult with other specialists about things outside their scope of practice rh doctors who had experienced working in urban hospitals expressed their frustration with this approach which meant they had to deal only with the problem the patients come for and nothing else …just deal with the problem and send them back out even if sometimes their other problems were actually contributing to the presentation holistic perspective rh doctors professed to having a broader mindset that supported a more holistic personcentred approach i think the biggest difference here and the thing we do best compared to the bigger hospitals is that we treat people as individuals it was recognised that having a holistic perspective helped acknowledging the challenges patients faced due to the context in which they lived … thats the advantage i have and i like about working across primary care is you see the context in which people live and realize how hard it is for somebody who doesnt have a car … to even get to for an xray… doctors considered that rhs offer some aspects of palliative care better than bigger hospitals such aspects were familiarity continuity and ability to avoid unnecessary procedures and treatments when patients would not gain from the intervention this was expressed as an ability to let people die with dignity one doctor described a patient who was terminally ill from heart failure he experienced a small gastrointestinal bleed and went through many invasive investigations in a larger hospital even though this would not lead to either cure or symptom relief instead it added to anxiety and confusion for the patient and family finally this rural doctor found out about what was happening and managed to stop further procedures this holistic perspective was together with the practical aspects described above considered important and many doctors compared rh palliative care provision to that of a hospice open access the good deaths people who are … theyve just reached the end of their time they may be well on in years they may have been suffering their heart condition or their cancer or whatever and their family are here they come into hospital and their symptoms are well controlled and everybody is happy and accepting you know its … if you can call any death a good death we do have plenty of those continuity of care another aspect of holism was relational continuity typical for the gppatient relationship a minority of participating doctors were working as gps in parallel to their work as rh doctors these doctors witnessed the advantage of being familiar with the patients circumstances when making medical decisions it could also be reassuring for patients in difficult situations to know the doctor one rural gp who had been working for decades serving the local population exhibited his compassion and empathy for those individuals with unfortunate fates that he had supported through the years i could have up to four generations of a family in my care at one time so after … excuse me … after nearly 30 years i get very close to them… …a kid i delivered who i then picked up off the road dead in a drunken car crash 18 years later doctors also described a continuity of care for patients associated with repeated hospital admissions at rhs including familiarity with the healthcare professionals working on the ward continuity of the patientdoctor relationship throughout the hospital stay was expressed as important for the patients striving to maintain patient safety this second main theme striving to maintain patient safety summarises subthemes weighing distance issues to keep or to refer patients and handling issues related to a dispersed population weighing distance issues to keep or to refer patients doctors considered that rural people deserve the same healthcare access as urban people they described how healthcare in rh areas struggle with patient safety issues related to long distances to base hospitals and the need for safe transportation of severely ill patients requiring ambulance access it was also discussed that even though many referred patients need transfer to a larger hospital because of their conditionthat is that they cannot be safely treated in the rhsome patients are referred because of practical issues related to long distances ambulance access as an ambulance could be gone for hours when transporting a patient to the base hospital doctors described concern about what to do if another sick patient needed ambulance transfer in the meantime but if i have got a sick patient who i need to transfer thats where im worrying for where the ambulance is and if its out of town doing a transfer youre always aware that its out of town doing a transfer as there was limited access to the local ambulance any patient that could go safely to base hospital by any other transportation would not be sent by ambulance referral because of distance rh doctors reported that local access to basic radiology and laboratory facilities was sufficient for most although not all acute situations some patients needed acute laboratory testing or radiology examinations to guide further actions that were not available in rural areas in such situations the decision had to be made as to whether the patient needed referral to the base hospital for these investigations handling issues related to sparsely populated rural areas among issues related to sparsely populated rural areas limited experience of or training in handling different conditions limited medical resources and limited medical staff were discussed related to these were discussions regarding vacancies among medical staff and recruitment initiatives like rural practice for medical students limited experience of handling different conditions doctors described a sense of insecurity when severely ill patients arrive at the rh although trained in emergency medicine they do not often meet these patients in the clinic ive put chest drains in people before ive intubated people before but not often doing those sorts of procedures ill do it if my back is shoved against the wall and i had to its gonna make me really uncomfortable yeah some of that stuff is scary it was discussed that since midwives took responsibility over the obstetric care in nz in the 1990s rural gps have lost their competences to deal with obstetric complications only one rh doctor interviewed was a trained obstetrician consequently in some regions expectant mothers can have a long way to go to give birth … if a midwife is looking after that woman identifies shes in need of an emergency caesarean she has to call an ambulance or a helicopter to get them to for an urgent operation therefore the delay will be a minimum of probably an hour and a half probably more likely two hours some patient groups are not admitted to all rhs such as psychogeriatric patients and children limited medical resources all rhs were reported to have access to plain xray and many of the rh doctors do pointofcare ultrasound examinations however with few exceptions rhs do not have a ct scanner consequently patients with stroke symptoms for example would be referred to a base hospital for diagnostics which including travel time could take hours open access the availability of pointofcare lab tests were also reported to differ between rhs and additional tests were wanted to improve patient safety limited medical staff the generalist rural health workforce across south island was acknowledged as having high turnover rates of doctors some doctors reported a lack of nurses physiotherapists midwives and dentists as well midwives we had the one midwife who was … you know her only 24 hours a day 7 days a week 365 days a year she was our only midwife here for years and finally she just had enough and said i quit different reasons for this were discussed living and working in the countryside does not suit everybody gps either hate it and they leave or they love it and they cant leave working in isolation far from hospitals could be frightening especially for unexperienced doctors and …if you work there as a doctor what does your partner do rural practice for medical students one problem described was that urbancentric health professional training programmes do not support a rural healthcare workforce doctors appreciated the rural medical immersion programme run by the university of otago where medical students do part of their clinical practice at rhs doctors stated that students get closer to the patient work and take more responsibility when doing their practice rurally compared with in a university hospital perceived patient safety many doctors argued that patient safety in rhs was as good as or better than patient safety in larger hospitals providing patients needing a higher level of hospital care were not retained arguments for this were shorter decision paths in rhs and medical staff knowing the social context of the patients which could favour discharge planning furthermore in rhs patients are often seen by an experienced doctor sooner than in a big hospital ive been here nearly 10 years and i cant think of a specific example of somebody who ive thought if that happened in central auckland then they would be alive so that must be quite rare i think its safe cooperating in different teams around the patient the third theme cooperating in different teams around the patient summarises subthemes working in small teams in flat organizations around the patient and consulting hospital specialists working in small teams in flat organisations around the patient the rhs take a central position in the healthcare pathways of rural patients rural doctors report team working when describing patient care together with other doctors within the rh with local gps and with hospital specialists in base and tertiary hospitals they are also part of multidisciplinary teams with nurses physiotherapists occupational therapists social workers and needs assessors within the rh and within their locality this does not differ from other hospitals but rural doctors discussed how small team sizes promote simplified collaboration between team members the impact on patients of varying numbers of staff involved in the hospital care was also discussed specifically the rh nurses role was highlighted as being central to the delivery of patientcentred care and adaptive to various clinical situations simplified collaboration doctors stated that the small size of rhs promotes nonhierarchical multidisciplinary teams where personal acquaintances and deeper understanding of each others roles simplify collaboration in this sense the small team size in rhs was expressed as an advantage compared with big hospitals i think theres less hierarchy here than in the bigger hospitals i think its much more egalitarian impact on patients the limited number of medical staff in rhs was described as an advantage for patients as they would not meet so many different medical staff hes in his 80s if he got a pneumonia and went to wellington hospital where he lives hed be seen by an emergency nurse an emergency doctor and then hed probably be admitted to a ward and see a junior doctor on a ward and then he might see a registrar on a ward and hed probably have a whole other set of nursing staff see him and do some sort of care plan and then youd have the specialists might see him for five minutes at some point and hed probably have some imaging at some point but thats already probably 15 different people would have been involved in his care whereas if he came to and got a pneumonia well my colleague xx whos on call tonight would see him and put him in the ward and organize his treatment and the nurses would the nurses that are there would be the ones that care for him conversely small team size was also considered a weakness and a vulnerability rural health professionals need broad clinical competencies whereas urban hospitals have more specialised staff available and if a member of staff falls ill it does not have such an impact on patient care were always one nurse short of a catastrophe down here if one nurse goes on leave and another nurse gets sick then all of a sudden we havent nurses role many doctors expressed their appreciation of the rh nurses for their broad competence their ability to adapt to different clinical situations and their clinical judgements particularly the nursing care i think thats probably the best thing about the ward some of the nurses are really exceptional at adapting to a whole lot of roles consulting hospital specialists in different medical situations rural doctors need to consult hospital specialists for advice on patient care they emphasised the interdependency between rural doctors and hospital specialists and the need for mutual recognition of each others situation they also reported varying levels of collaboration with different hospital clinics interdependency and mutual recognition overall cooperation with those working in urban hospitals was described as good this cooperation was improved by personal knowledge and mutual recognition of each others circumstances … i think we work alongside each other i couldnt do my job without a cardiologist who i refer to or a cardiac surgeon to refer to they also couldnt do their jobs without me doing what i do and finding patients for them and treating them before and after… however some doctors described limited understanding from urban hospital staff about the restricted resources available in rhs and about contextual factors that influence the medical decisions taken in rhs the perception that some rhs were more trusted and listened to by hospital specialists than others was discussed varying collaboration with different hospital clinics it was considered that some hospital clinics tended to collaborate better with rh doctors than others things like oncology and paediatrics we have really good easy access to the specialists and they are really personable and you can ring them about anyone whereas orthopaedics oh my god its like a nightmare you can never get the same person on the phone and then you always have to talk to the junior staff so you cant actually ask questions about people that might be quite sophisticated… discussion principal findings three themes were identified applying a holistic perspective in the care striving to maintain patient safety in sparsely populated areas and cooperating in different teams around the patient participating doctors considered rhs provided a more holistic perspective on patient care based on closeness to home and family a generalist care perspective and greater relational continuity than hospitals in larger centres findings also demonstrate the different assessments rh doctors make which urban doctors are not required to do the central role of the rhs in the healthcare pathways of rural patients was discussed as well as advantages and disadvantages with small nonhierarchical multidisciplinary teams for patients comparison with existing literature the rh doctors appreciated providing holistic care in contrast to the alleged narrow biomedical perspective of hospital specialists in larger hospitals rhs were considered a suitable setting for the care of multimorbid elderly patients 6 7 8 9 moffat et al concluded that management of multimorbidity requires a holistic approach by a generalist 24 in agreement with our findings close to home is multifaceted as both close and home can have different definitions in a geographical sense our findings are consistent with those from interview studies involving patients that describe having hospital care close to home as a great advantage 25 the emotional sense of home including homeliness and personal connections discussed in our study is also described in patient interviews 17 18 26 it was obvious that rh doctors in our study not only considered the patients treatment as important but also the patients lived experience of their hospital stay as important reflecting the social aspect of their holistic perspective home means different things for different individuals depending on their ethnicity and beliefs our study recognised that being near to their whānau is particularly important at end of life for māori patients as also reported in the study from the north island by blattner et al 16 a systematic review 27 concluded that home is the preferred place of rural death and that when symptom control cannot be catered for at home rhs may act as substitute hospices compared with general hospitals ruralcommunity hospitals have been regarded as preferable places for endoflife care 28 continuity of care is often discussed in relation to primary care with an established positive relationship between interpersonal continuity in the gppatient relationship and patient satisfaction 29 our results show that in the rh setting relational continuity could include interpersonal relationships within the community and for patients with repeated hospitalisations familiarity with health professional on the ward as reported elsewhere 30 from the rh doctors point of view this continuity was helpful in medical decisionmaking particularly for rh doctors working as gps in the community as well strong overlapping personal and professional relationships with community memberspatients can emerge over time 31 described at times as a burden for the small town doctor by mccarthy 32 and reported in our study as well open access long distances to the nearest ed increase mortality risk for patients with specific emergency caresensitive conditions intracranial injury acute myocardial infarction other acute ischaemic heart disease fracture of the femur and sepsis 33 34 in south island long distances to eds are the rule rather than the exception due to the dispersed population many rural areas are serviced by only one ambulance crewed by volunteer st john staff so when the ambulance is away transporting a patient this could delay transportation of subsequent acute patients some acute conditions present as highrisk lowfrequency situations to rh teams and doctors may lack recent management experience of these so such situations can be very stressful for the team and potentially dangerous for the patients as discussed by our participants and described elsewhere 35 to address this ruralspecific postgraduate training programmes have been developed and implemented in nz 4 27 36 including simulationbased training 37 patient safety is a wide subject to discuss in this study the expression was used without definition and therefore discussed intuitively by the doctors rh doctors stressed the importance of treating the right patients in rhs this highlights the significance of the assessments made when deciding whether to keep a patient or to refer to a base hospital this decision process has been studied elsewhere 38 39 and a common finding is that these decisions are not governed solely by the patients medical condition but by contemplations of the doctor about rh capacity regarding available beds and diagnostic investigations staff competences transferring capacity and so on our study confirms the heterogeneity of assessments rh doctors perform when making these decisions most rh doctors asserted that the patient safety in their rh was high even possibly higher than in a base hospital studies in nz and internationally have not found any association between rural location and increased risk of hospital harm but patients in need of interhospital transfers were at increased risk 40 41 as would be expected with patients with emergency caresensitive conditions rh doctors considered that their small sized informal and egalitarian teams enhanced holistic care simplified collaboration and reduced the impact on patients of fragmented care driven by a high volume of healthcare professionals this finding is similar to a swedish interview study on interdisciplinary teamwork that identified a holistic care approach and proactive nonhierarchical interaction as important factors for quality geriatric care 42 small working teams do not need formalised reporting mechanisms if they have relationships that enable open disclosure and resolution of errors 43 however due to the overlapping of professional and personal roles some small medical communities may need structured reporting mechanisms to ensure anonymity 43 strengths and limitations of the study the interviewing researcher had specific knowledge in rural medicine as a swedish rural gp but no previous relation to the rhs or the medical staff interviewed which is considered a strength conversely his preunderstanding could cocreate the messages from interviews with participants and play a role in the subsequent analysis however the latter was balanced by other experienced qualitative researchers in the process looking at the text data through different analytical lenses another strength is the diversity of rhs visited the interviewers first language is swedish and interviews were performed in english therefore linguistic nuances could be misinterpreted however repeated readings of the transcripts and interviewees reports from reviewing their transcript did not reveal such misinterpretations many of the doctors had long clinical experience from working in nz and overseas that would add to richness in information when discussing genderrelated aspects on their work in rhs the female doctors did not report anything of value to the study we aspired to have māori representation among interviewees but in the rhs visited no doctor identified as māori and it is acknowledged that māori are underrepresented in the nz medical workforce 44 in the last two interviews no new information of importance was added indicating that saturation was met the chosen perspective in this study is that of rh doctors perspectives of other members of rh teams patients and relatives are important and require exploration in subsequent studies we emphasise that some of our findings are not necessarily transferable to rhs in north island as there are considerable sociodemographic differences between the populations of north island and south island notably in distribution of the māori population in rural areas 45 implications for clinical practice and health policy a recent nz policy document emphasises the estimated increase in hospital bed usage in the coming decades due to an ageing population and emphasises that the complexity of hospital cases will increase due to multimorbidity and frailty 4 hospitals need to work more closely with community social and primary care services in locally integrated systems to ensure that people are only cared for in hospital when appropriate 4 generalistled hospital care is considered especially suitable for multimorbid elderly patients that require a holistic approach by the caregiver 24 the 2006 otago rural hospital study 6 suggested that approximately 40 of admissions from urban populations to base hospitals could be handled at a generalist levelas is now provided in rural settings using the rh model given the need for more hospital beds in future 4 the rh model of care could be suitable for piloting in semirural and urban nz conclusion this study provides an understanding of how nz south island rh doctors perceived the importance of the provision of a holistic generalist model of hospital care for data availability statement all data relevant to the study are included in the open access patients and for their rural communities as well as the significance of the rh to rural communities twitter tim stokes stokestim63 acknowledgements the authors would like to thank all the participating rh doctors and the managing directors of their rural hospitals for their involvement and effort contributors mh designed the study and developed the interview guide in cooperation with mb ts and fdn mh conducted the interviews initial data analysis was undertaken by all authors subsequent data analysis was undertaken by mh and mb with input from ts and fdn mh led the writing of the manuscript with inputs from mb ts and fdn mh is the guarantor competing interests none declared patient and public involvement patients andor the public were not involved in the design or conduct or reporting or dissemination plans of this research patient consent for publication not applicable ethics approval this study involves human participants and was approved by otago human ethics committee participants gave informed consent to participate in the study before taking part provenance and peer review not commissioned externally peer reviewed

objective to explore rural hospital doctors experiences of providing care in new zealand rural hospitals design the study had a qualitative design using qualitative content analysis setting the study was conducted in south island new zealand and included nine different rural hospitals respondents semistructured interviews were conducted with 16 rural hospital doctors results three themes were identified applying a holistic perspective in the care striving to maintain patient safety in sparsely populated areas and cooperating in different teams around the patient rural hospital care more than general hospital care was seen as offering a holistic perspective on patient care based on closeness to their home and family the generalist perspective of care and personal continuity the presentation of acute lifethreatening lowfrequency conditions at rural hospitals were associated with feelings of concern due to limited access to ambulance transportation and lack of experience overall however patient safety in rural hospitals was considered equal or better than in general hospitals doctors emphasised the central role of rural hospitals in the healthcare pathways of rural patients and the advantages and disadvantages with small nonhierarchical multidisciplinary teams caring for patients collaboration with hospital specialists was generally perceived as good although there was a sense that urban colleagues do not understand the additional medical and practical assessments needed in rural compared with the urban context conclusions this study provides an understanding of how rural hospital doctors value the holistic generalist perspective of rural hospital care and of how they perceive the quality and safety of that care the long distances to general hospital care for acute cases were considered concerning

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introduction retirement is one of the major life events that affects peoples subjective quality of lifesubjective wellbeing although intensive research on this topic has been conducted the evidence on the impact of retirement on life satisfaction has been mixed 1 retirement has been analysed from different angles with many scholars investigating the effect of retirement on an individuals subjective quality of life as van solinge and henkens noted researchers usually adopt an individualistic approach to studying retirement even though it can be perceived not only as an occupational career transition but as a family transition that is also experienced by couples 2 research on retirement can for example investigate whether it is voluntary whether a retiree takes up bridge employment 4 and whether an individual retired at the regular statutory age or early 5 an individual may transition to retirement while unemployed or while employed 6 similarly the impact of retirement on individuals can by scrutinised from the shortterm or the longterm perspective 78 furthermore job satisfaction appears to play a role in the transition to retirement it has for example been shown that having lowquality work is associated with a higher probability of becoming unemployed and of retiring early through either full or partial retirement 9 moreover as mortality has decreased in recent decades and life expectancy has reached unprecedented levels the length of time people spend in retirement has been increasing as well with a growing number of individuals spending 20 30 and even 40 years in this stage of life thus the duration of this life phase may have an impact on older peoples subjective quality of life and on the broader society and social policy all of these situations and factors as well as individual sociodemographic and economic characteristics personality traits and experiences may mitigate or enhance the relationship between retirement and subjective wellbeing for example having a higher level of education may enable an individual to secure a better job and more financial resources which can in turn lead to greater life satisfaction 10 11 12 similarly married adults are happier than those living without a spouse 101314 while people who have a disability or longterm health problems tend to be less satisfied with life 101516 in addition the assets people accumulate over their life course advantages may influence their process of adapting to retirement and thus their subjective quality of life 17 18 19 the results of analyses of the relationship between personal traits and subjective wellbeing in the context of the transition to retirement have shown that certain personality characteristics may be associated with increased swb because they ease the process of adaptation to a new stage of life 20 in the temporal process model of retirement the transition from work to retirement is conceptualised as a process consisting of three sequential phases retirement planning retirement decisionmaking and retirement transition and adjustment 21 in this study we focused on the last phase in order to gain a better understanding of how transitioning to retirement affects an older persons subjective quality of life as approximated by the happiness level and loneliness thus the main objective of this study is to analyse the impact of retirement on happiness and loneliness levels in poland in particular we seek to investigate whether having a job after retirement influence swb and loneliness for this purpose we draw on data from five waves of the social diagnosis the conditions and quality of life of poles panel survey we employed fixed effects logit models and fixed effect ordered logistic models with the blowup and cluster estimator for panel data unlike crosssectional data panel data allow us to control for unobservable heterogeneity by gathering analogous information on individuals at different points in time thus the changes in subjective quality of life may be interpreted by examining the changes in respondents characteristics or situations to the best of our knowledge this topic has rarely been investigated for poland especially with the use of panellongitudinal data 22 moreover poland together with other centraleastern european states belongs to a group of countries with rather low subjective quality of life levels 23 24 25 26 thus additional research on the determinants and the effects of different life decisions events and situations on subjective quality of life in poland is needed furthermore this analysis can help to broaden our understanding of the retirement process as one of the key changes in the individual life course and of the impact of retirement on individual psychological wellbeing as such insights are crucial to efforts to prolong working life in order to reduce the negative consequences of the population ageing process in poland in the next section we provide a review of the literature on the impact of the transition to retirement on subjective quality of life among older workers and among older people in the early stages of retirement then we describe the data and methods we used in the study finally we present our empirical results and our conclusions in this paper in line with other studies on this topic 27 we use interchangeably the termsconcepts of subjective quality of life psychological wellbeing life satisfaction and happiness as they are strongly interrelated and characterise different aspects of quality of life retirement and subjective quality of life a literature overview transition to retirement and subjective quality of lifea review of theories the existing literature has offered a number of theoretical perspectives on how retirement affects an individuals wellbeing the role theory views retirement as a transition from work roles to nonwork roles the effect of moving from employment to retirement may be either negative or positive depending on an individuals level of involvement in work roles relative to level of engagement in other roles people who invested a lot in their workrelated roles or for whom work was an important part of their identity may experience lower levels of wellbeing anxiety or depression when they retire by contrast people who found their job stressful and burdensome or who wanted to be more involved in their family member or community member roles may experience retirement as a positive change or even as a relief 29 according to the continuity theory 30 individual patterns of behaviours activity profiles and social engagement are consistent over time which suggests that people tend to follow familiar strategies at different moments of life hence continuity is the main adjustment strategy 31 this means that the process of retirement consists not only of the termination of paid work but also of many different individual characteristics and of the actions a person takes to adjust to new circumstances which can in turn enable himher to preserve the level of subjective quality of life after retirement 32 therefore retirement is not necessarily a negative event especially if an individual is able to maintain the lifestyle patterns established before leaving employment or if the individual perceived retirement as part of a prior plan for later life another theoretical framework for analysing retirement is the life course perspective which focuses on the context in which people live their lives 3334 this perspective regards retirement as both a transition and a trajectory that is embedded in contextual circumstances consequently in accordance with the linked lives paradigm an individuals perception of retirement experience may vary by for example whether a person is married or how strongly heshe identifies with family roles 29 finally the adjustment to retirement can be viewed as a resourcebased dynamic process 129 the point of departure for this theory is the observation that retirees do not follow a uniform adjustment pattern during the retirement process 29 within this framework changes in the trajectory of an individuals life satisfaction after retirement are a reflection of the gains and losses in personal resources that accompany the transition to retirement these resources can be physical cognitive motivational financial social or emotional and can be accumulated over time moreover these resources are influenced by a variety of antecedents including variables at the macro level the organisational level the job level the household level and the individual level 1 retirement and life satisfaction previous findings retirement is considered one of major late midlife events that affect subjective wellbeing however the results of previous research on the impact of retirement on swb have been inconsistent 135 some studies have found that retirees have higher levels of life satisfaction than workers especially in the early stages of retirement 67 36 37 38 it has been argued that retirees often enjoy having free time and feel released from the pressures of employment 36 other researchers have found that retirement has no effect on subjective wellbeing 2022323940 or on the probability of becoming depressed 5 the sense of control over the transition appears to be of great importance the association of retirement with loneliness depends on whether the transition to retirement was voluntary or involuntary with involuntary retirement being associated with higher levels of loneliness 41 there is also evidence that involuntary retirement has adverse effects on a persons life satisfaction 442 the transition to retirement cannot be seen as a uniform process because individual life histories can vary greatly the assumption that the transition to retirement can take different forms was confirmed in a study based on data from the us health and retirement survey 29 the results showed that of the retirees in the study sample around 70 experienced no change in psychological wellbeing less than 5 experienced a positive change in wellbeing and 25 suffered a decline in wellbeing similar percentages were found by pinquart and schindler 43 using german data of the retirees in their sample 15 experienced an increase in life satisfaction 9 experienced a decrease in life satisfaction while the majority reported no significant change in wellbeing moreover sohier et al demonstrated that while life satisfaction does not change immediately after retirement it is diminished two years after this transition 40 similar results were obtained by hellersahlgren who found that while retirement has no effect on mental health over the short term the depression levels of retirees increase significantly over the long term 44 similarly segelkarpas ayalon and lachman observed that depressive symptoms increase after retirement 45 against this background scholars have long been interested in identifying the factors that influence the differences in life satisfaction levels during the retirement transition in their review wang et al summarised the variables that influence how well people adjust to retirement using five categories individual attributes preretirement jobrelated variables familyrelated variables retirement transitionrelated variables and postretirement activities 1 szinovacz argued that financial status health and individual attributes are the main attributes associated with wellbeing in retirement 46 both of these studies have received considerable attention in the literature one of the most important consequences of transitioning to retirement is a considerable decrease in economic resources 47 which may have a negative impact on subjective wellbeing as a favourable financial situation has been shown to contribute to higher levels of life satisfaction after retirement mostly among men 48 however this effect may be mitigated or reinforced by the wealth a retiree accumulated during ones working life in general the better the financial status of an individual is the lower the risk that a person will experience a decline in life satisfaction during the transition to retirement 743 similarly yeung observed that retirees who can maintain the level of resources they had while working do not experience a decrease in wellbeing after retirement 47 in contrast calvo haverstick and sass found that wealth has no significant effect on the happiness of retirees 49 transitioning to retirement means that an individual experiences a change in daily activities and is able to choose between leisure activities volunteer work and paid work 21 it has been shown that retirement tends to increase the proportion of time people spend on leisure social and cultural activities 50 as well as on domestic tasks and volunteer work which can include caring for family members or being involved in organisations 51 bonsang and klein argued that retirement has two effects a sizable positive effect on satisfaction with free time and a sizable negative effect on household income they therefore concluded that the average effect of retirement on life satisfaction is negligible 42 the association between an individuals health status and retirement is bidirectional on the one hand physical and mental health are strong predictors of the decision to retire 455253 and of retirement timing ie individuals who are in better physical health are more likely to retire later 5455 and to engage in postretirement paid work 21 moreover an opportunity to retire early may have positive effects on a persons mortality and health 56 on the other hand the effect of retirement on an individuals health status depends on personal characteristics and life history in the retirement adjustment process physical health is considered an important resource that accumulates over the life course therefore individuals with worse health are at risk of experiencing a decline in life satisfaction when transitioning to retirement 17184348 in general research on the linkages between health and retirement has found that retirement does not increase the risk of health deterioration indeed it has been shown that retirement contributes to better selfreported health and reductions in activity limitations for both men and women 56 57 58 59 however these patterns appear to differ across socioeconomic groups for example some studies observed improvements in health status for individuals of all educational levels 59 while other studies found improvements only for individuals with high socioeconomic status 60 similar results were reported by gorry et al who found that selfreported health increases after retirement especially over the longer term 39 a potential explanation for this finding is that retirees make positive changes in their healthy behaviours and are more engaged in social activities as being in better health enhances subjective wellbeing 1516 if a persons health improves after retirement life satisfaction may increase as well similarly calvo et al observed that improvements in health are associated with higher levels of happiness and enjoyment of life and with lower levels of loneliness depression and sadness 49 the relationship between preretirement and postretirement employment and subjective quality of life is also worth examining while it is common for retirees to continue to engage in paid work and to acquire pension benefits after the transition to retirement the relationship between working and swb in retirement remains unclear for example it has been shown that individuals who continue to work after retirement are as satisfied with life as those who stopped working completely 40 other studies have found the opposite effect ie that bridge employment enhances the life satisfaction levels among people who retired voluntarily and reduces the decline in life satisfaction among people who retired involuntarily 4 it is worth noting that this relationship depends on the cultural context and the employees qualifications 61 there is also evidence that having a paid job after retirement lowers depression levels 32 although this effect appears to be moderated by whether the work is voluntary or involuntary it has for example been shown that pensioners who are forced to prolong their working life after retirement because of their circumstances are less satisfied with life than those who do not continue to work 62 moreover often even if a retiree is working voluntarily the job may be of low quality or beneath ones qualifications which may reduce the individuals subjective wellbeing after retirement in terms of preretirement jobrelated variables whether an individual was unemployed before transitioning to retirement and the challenges and stress levels faced in the workplace can affect the emotional consequences of retirement it has been observed that retiring from unemployment may be more beneficial than from retiring from employment because it can improve the individuals income and status 643 in addition it has been shown that retirees who retire from highly physically demanding jobs are more likely to experience positive changes in psychological wellbeing than retirees who retire from less physically demanding jobs 2963 there is also evidence that job dissatisfaction contributes to greater satisfaction with life after retirement 48 in this context the findings of damman et al are interesting as they pointed out that retirees can miss work for different reasons depending on their career path in midlife 64 they found for example that retirees who had a steep upward career path in midlife were less likely than those who did not experience upward mobility to miss their moneyincome but were more likely to miss their status social networks are also crucial elements of the decision to retire the timing of retirement and the impact of retirement on wellbeing the size of a persons social network and the intensity of contacts with its members are positively related to early retirement 65 moreover the composition of an individuals social network particularly the presence of a spouse as the person with whom the person has the most frequent contact increases the risk of early retirement in addition to having a spouse the timing of retirement is influenced by a persons employment status 65 having a working spouse lessens the chances of retiring earlier while having a spouse who does not work has the opposite effect it has been shown that for older women in particular their social contacts in the period prior to retirement are especially crucial for their swb 48 among the familyrelated variables the quality of the marital relationship stands out as a predictor of satisfaction with retirement 2 an individuals marital history appears to play a role as well as a divorced retiree without a partner is especially likely to have difficulties adjusting to the social changes associated with the loss of hisher work role 64 retirement in poland poland which is the focus of our analysis can be described as a country with an early retirement tradition two major pension reforms aimed at increasing the actual and the statutory retirement age have been introduced in poland the pension reform of 2009 reduced the options for retiring early by eliminating a number of early retirement schemes additionally actions were taken to reduce eligibility for disability benefits 66 as a result the employment rate in poland for people aged 5564 increased from 316 in 2008 to 443 in 2015 and to 495 in 2019 however the employment rate for older people in poland still lags behind the eu28 and the oecd average the reform of 2013 was expected to improve the adequacy of pensions and the financial stability of the pension system it introduced unification of the statutory retirement age for men and women with a formula designed to gradually increase it to 67 years before 2013 the statutory retirement age was 60 years for women and 65 for men from 2013 onwards the pension eligibility age was increased gradually by four months per year and is on track to reach 67 years in 2020 for men and in 2040 for women 67 in 2017 changes in the statutory retirement age were introduced that lowered it to 60 years for women and to 65 years for men although the average age at which people started receiving oldage pension benefits increased from 615 years for men and 58 years for women in 2005 to 628 years for men and 606 years for women in 2018 68 this level is still below the statutory age for men from a comparative international perspective the effective labour force exit age in poland is lower than the european union and the oecd average especially for women additionally the polish population is ageing fast as the share of people aged 65 or older in the total population is projected to increase from 177 in 2019 to 339 in 2060 69 while poles retire early for many different reasons the desire to retire as early as possible is widespread in the country 7071 as a consequence the employment rates of people aged 5064 are very low in poland and unemployment in this group often leads to complete inactivity rather than to reemployment 72 thus a persons motives for retirement and individual characteristics and history may influence the decision about when to retire and the effects of retirement on subjective quality of life based on the literature review described above we propose the following research hypotheses retirement transition does not affect the happiness level and loneliness among retiring poles continuing professional work after retirement is beneficial for subjective wellbeing reduces loneliness the effect of retirement on subjective quality of lifeloneliness is similar for men and women in poland materials and methods data for our analysis we used data from the social diagnosis living conditions and quality of life of poles panel survey which was carried out in poland in 20002015 73 this was a comprehensive survey that covered various aspects of the living conditions of households and their individual members specifically it collected data on the economic aspects as well as the noneconomic aspects of the lives of individuals a total of eight waves of this survey were carried out in all eight waves conducted in the 20002015 period data on more than 62500 respondents aged 16 years or older were collected 73 however for the purposes of our analysis we limited the sample to the respondents aged 5569 who participated in the last five waves of the survey and who transitioned to retirement over this period in our analysis we omitted the data from the first three waves of the social diagnosis survey because they did not allow us to determine the retirement status of the respondents unequivocally we also removed the observations with missing values for all of the variables in the models importantly our sample was restricted to respondents who participated in at least two waves of the study which was conditioned by the employed models the numbers of the respondents in the subsequent waves changed due to the attrition effect and the expansion of the sample which resulted in an unbalanced panel the final sample contained information on 1503 observations across all five waves table a1 presents the number of observations in the final sample in all five waves variables in the models dependent variable in our analyses we concentrated on happiness as a dimension of subjective quality of life which was based on the following question all in all how would you assess your life in recent timeswould you say you are with four possible answers 1very happy 2rather happy 3rather unhappy and 4very unhappy however for the purposes of our analyses we changed the order so that 1 signified very unhappy and 4 signified very happy this variable captured temporal changes in happiness the loneliness variable was based on the question do you feel lonely even though you do not want to with two possible answers yes and no control and explanatory variables in order to answer our research questions we included a set of explanatory variables in the models that encompassed not only the basic sociodemographic and economic characteristics of the individual respondents but also the variable describing their retirement status in particular we incorporated the following variables into the basic models sex and satisfaction with ones health status our key explanatory variable describing the retirement status of the respondents was derived from the information on the reason for economic inactivity ie based on their statements that they were not working because they were retired however a share of the retired respondents could work as the employment status of these respondents showed the reference category for the retirement status was not retired the categorical variables after necessary transformations were included as a set of binary variables with the reference categories that are described above three variables were treated as continuous table a1 presents the descriptive statistics for all the covariates in the models in all five waves methods in our approach we used panel data to determine the effects of different variables on happiness and loneliness which allowed us to control for unobserved heterogeneity among individuals life satisfactionhappiness may be introduced into econometric models as a latent variable measured on a continuous scale whereas what we observed is an answer to the survey question measured on an ordinal scale thus in this estimation procedure the ordinal character of the dependent variable with values from 1 to 4 was taken into account in this paper we estimated a fixedeffects ordered logit model which may be expressed as follows y it x it β α i it i 1 n t 1 t where y it stands for unobserved happiness level x it stands for a vector of observed individual characteristics β stands for a vector of coefficients α i stands for individual specific intercepts and it stands for a timevarying unobservable term that is independent and identically distributed with a standard logistic cumulative density function the observed happinesslife satisfaction is related to the modelled unobserved y it in the following way y it        1 if y it ≤ µ 1 2 if µ 1 y it ≤ µ 2 3 if µ 2 y it ≤ µ 3 4 if µ 3 y it fixed effects models are often used in social sciences including in analyses of the effects of retirement 48 because they can be used to estimate casual effects by controlling for unobserved individual heterogeneity while several estimators are used in model estimation in this study we employed the blowup and cluster estimator proposed by baetschmann et al 7475 it has been proven that the buc estimator has good properties and is as efficient as more complex estimators this estimator was implemented in a stata command feologit which allows for estimation of other model elements in this method of estimation is it implied that each individual has different thresholds thus the estimates generated by this method are not provided in the tables with the results moreover the program excludes respondents who were observed only once or did not differ with respect to a dependent variable between waves in contrast for a binary dependent variable describing loneliness we employed a fixedeffects ordered logit model for all the dependent variables we estimated the models for the total population aged 5569 and for males and females separately in order to investigate the differences between the sexes moreover to investigate the relationship between retirement status and employment status we estimated similar models but with the interaction between the two covariates results the estimation results of the models for happiness are presented in table 1 in model a we introduced separate variables describing retirement status and employment status while in model b we incorporated the interactions between those variables in order to account for the differences between individuals who continued working after retirement most of the coefficients were found to be significant at the 001 level generally speaking the effects of the majority of the control variables in all of the models were consistent with the findings described in the literature devoted to subjective wellbeing however some differences between the models were detected as for the relationship between retirement and the happiness level the results of model 1a showed that among the people who retired in the analysed period their level of happiness did not change significantly after they retired similar outcomes were obtained in model 1b with the interaction terms between retirement status and employment status neither stopping work nor continuing to work after retirement affected the respondents levels of happiness after they retired these findings may suggest that there are different groups of people who experience the transition to retirement in different ways as shown by for example the authors in 43 thus the mean effect of retirement on swb for a studied population may be insignificant or minor it is also worth mentioning the results we obtained for the other variables in the models for instance we found that partnered men and women were happier than those living without a partner which is in line with the results of previous research 10 76 77 78 having a better financial situation was found to be associated with higher levels of happiness in the analysed group which is consistent with the findings of previous research 1279 although the estimates for disability turned out to be insignificant satisfaction with ones health status was shown to contribute to higher levels of happiness which confirms the outcomes of other analyses 158081 in addition being employed was found to be positively related to happiness among females only a different picture emerged in model 2 which included loneliness as a dependent variable the results of model 2a showed that retirement increased the risk of loneliness among men but not among women a more detailed image can be observed when the interaction between retirement status and employment status is taken into account our outcomes demonstrated that males who retired and did not continue to work had a higher probability of being lonely than those who were not retired and were not working while the results for females were insignificantly negative moreover we found that the respondents who had retired and were still employed were less likely to be lonely than the respondents who were not working and not retired and that this effect was bigger for men these findings suggest that after men retire their social networks tend to shrink which may lead to diminished social interactions and in turn to higher levels of loneliness to conclude these results may indicate that there was a positive relationship between bridging employment and subjective quality of life among this group as loneliness was related to depression and thus to lower swb discussion the aim of this paper was to analyse the relationship between retirement and happiness and loneliness among people aged 5569 in poland to some extent our results are in line with those reported in the literature review in general in the models without interactions the happiness levels of the surveyed individuals did not change after they retired a similar pattern was observed when the interactions between retirement and employment were introduced we obtained more information from the models with loneliness as a dependent variable first retirement increased the probability of loneliness among males second the interaction between retirement status and employment status showed that not working after retirement increased the likelihood of being lonely among men while engaging in bridge employment decreased the chances of being lonely among men this finding may suggest that combining retirement with employment may be a source of social interactions which can protect people from loneliness and which may in turn be positively related to other factors in terms of our research hypotheses our results allowed us to draw the following conclusions retirement did not change happiness levels but it did have an impact on loneliness as men who continued working after retirement were less lonely and individuals who were not working after retirement were more lonely than individuals who were not working and not retired this work contributes to the research on subjective wellbeing in retirement through its focus on poland a central european country with a culture that promotes retiring as early as possible 7071 this is especially important in the context of the approach we used in our analysis of focusing on individuals for whom we could observe the transition to retirement however this analysis has some limitations first we used singleitem questions as the dependent variables describing happiness and loneliness although they capture the studied phenomena quite well more complex variables composed of different dimensions of subjective wellbeing or loneliness would be more appropriate and more informative in this context secondly we excluded from the final dataset individuals who retired at younger ages and who may make up a substantial share of the original sample as well as individuals who retired at older ages moreover we did not distinguish between early and regular retirement which could help to differentiate the results and shed some light on the impact of early retirement on swb among poles therefore future analyses should focus on this topic as well furthermore since the study was carried out every two years it was impossible to detect the exact time of the event of interest which may have affected our results in particular it would be interesting to investigate the shortterm and the longterm consequences of retirement on subjective wellbeing and to thus verify the continuity theory 30 another issue is the endogeneity of retirement which may be caused by many reasons for example health status may have impact both on retirement decision and subjective wellbeing while the omitted variables such as job satisfaction or caring responsibilities may also influence simultaneously a withdrawal from the labour market and subjective quality of life while the dataset we used in the analyses provided us with the main control variables having additional informationsuch as information on preretirement jobrelated variables individual attributes motives for retirement whether the retirement was or was not voluntary and characteristics of bridge employment could improve our understanding of the process of the transition to retirement in poland unfortunately the social diagnosis survey ended in 2015 but it could become an important source of information on subjective quality of life for poles at all ages including for those nearing the retirement age or in the early years of retirement furthermore a longer panel would allow us to study the wellbeing trajectories of different subpopulations and to evaluate whether any changes in happiness levels are temporary or stable over time moreover such data could shed new light on the relationship between the transition to retirement and subjective quality of life in recent years among new cohorts of retirees especially given the changes in the statutory retirement age and the growing social awareness of demographic changes and of the consequences of increasing life expectancy on pension benefit amounts conclusions we believe that research on the transition to retirement is extremely important because this event triggers changes in many areas of a persons life including psychological wellbeinglife satisfaction and organisation of daily activities as well as health status and mortality these consequences may differ for different subpopulations especially those who retired earlier or those with lower socioeconomic status which may require the development of different social policies aimed at improving the quality of life of disadvantaged populations this is especially important in the context of efforts to prevent unequal ageing and to help individuals reduce their risk of detrimental outcomes including poor health and poverty in old age 82 future studies should seek to fill this research gap for poland furthermore it appears that having a paid job after retiring plays a different role for different subgroups especially for men thus a deeper investigation into the relationships between job characteristics retirement and subjective quality of life is needed data availability statement data are available on author contributions aak concept and design literature review data analysis description of results preparation of a draft manuscript review of the manuscript and coordination of the project within which the study was conducted wł concept and design literature review data analysis discussion of the results and review of the manuscript both authors have read and agreed to the published version of the manuscript appendix a

this paper examines the impact of retirement on peoples subjective quality of life as expressed by their levels of happiness and loneliness in poland we analysed five waves of the social diagnosis panel survey conducted between 2007 and 2015 to account for unobserved individual heterogeneity we employed fixed effects ordered logit models and fixed effect logistic models for the panel data we found that the respondents happiness levels did not change after they retired and that the introduction of interactions between retirement and employment did not alter these findings however the results of the loneliness model showed that the probability of being lonely increased among males after retirement second the outcomes of interactions between retirement and employment suggested that not working after retirement increased the likelihood of being lonely among men whereas engaging in bridge employment decreased the chances of being lonely among men these findings may indicate that combining retirement with employment may be a source of social interaction which can provide protection against loneliness and which may in turn be positively related to other factors ie subjective quality of life health status and mortality

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introduction ver the past 20 years genderbased violence has increased affecting one in three women in their lifetime violence against women refers to a myriad of genderedbased acts almost exclusively directed at women and girls that can cause direct or indirect harm over their lifespan the world health organization describes violence against women as an act of genderbased violence that results in or is likely to result in physical sexual or psychological harm or suffering to women including threats of such acts coercion or arbitrary deprivation of liberty whether occurring in public or private life while rates of policereported gendered violence have decreased in canada nearly 70 of violence remains unreported to the police and women continue to live at greater risk for domestic violence sexual assault and harassment demonstrations of harm and abuse include physical aggression psychological violence neglect and control over speech and actions in severe instances these acts may result in death given the secondary status of women within families states and societies it is not uncommon for gendered violence to be observed as ordinary or in some cases socially sanctioned while subordination may not be the perpetrators motivation it may result as an indirect consequence of their actions these actions may remain concealed by victims in fear of being further attacked or violated thus violence against women is not only rooted in sex inequalities present in ones social world but also serves as a mechanism to sustain unequal powers and reinforce the status of vulnerability that fuels the abuse the advent of technology has allowed new mechanisms of genderbased violence to emerge that may allow users to inflict harm against women through online hate and cyberviolence while individuals of all genders experience technologyfacilitated abuse the canadian womens foundation has indicated that women are at heightened risk of experiencing online violence harassment and sexualised abuse research on technologyfacilitated abuse has shown that digital technologies are used routinely for online stalking impersonation harassment and abuse sometimes under a concealed identity scholars have raised concerns over the growing use of technology a diverse range of sophisticated tools to abuse control and intimidate victims are widely accessible within the digital fieldoften free of cost progress in the field of artificial intelligence specifically machine learning has allowed users to readily create altered media content online amassing large and often global audiences in onandoffline spaces amongst these advancements is the emergence of deepfake technology henceforth referred to as deepfakes broadly deepfakes are machine learningbased software tools that produce realistic synthetic media content deepfakes replace the likeness of one individual with another making the target individual appear to say things or perform actions that the source individual does the generative adversarial networks had been mainly restricted to the ai research community until 2017 when a reddit user using the anonymous handle deepfakes began posting digitally altered pornographic videos through a free opensource machine learning software the reddit user built gans to superimpose celebrities faces on adult film stars for pornographic purposes in 2023 twitch streamer brandon atrioc ewings inadvertent disclosure of his previously viewed deepfake pornography of wellknown female twitch streamers further highlighted this problem this incident exposed the creators exploitation of womens deepfakes for profit as ewing had inadvertently revealed the paytoview subscription site that hosted such content to his live audience in recent years the use of deepfakes has risen in popularity due to the quality of synthetic media content and the ease of their applications for users with limited or sophisticated computer skills although deepfakes can be produced with the approval of the featured individuals they are commonly created without consent new developments have allowed for sophisticated deepfake videos to be produced with a still image permitting any digital human trace to be fabricated and further threatening privacy moreover in a posttruth era deepfakes are often utilised with malicious intent to influence popular beliefs or damage the methodology the researchers of this review examined the literature exploring the harms women have experienced through technology and deepfakes a narrative review was conducted as it allows for descriptive and critical investigation without simplifying results into standard metrics this review involves emerging scholarly literature news and media articles and peerreviewed studies from technological sectors that may provide insight into the characteristics of threats brought forth by digital technologies and deepfakes a search was conducted for scholarly literature and peerreviewed articles on google scholar and in the omni database google search engine was used to scan news and web articles exploring cases of deepfake and deepfake technology searches included the following search terms cyber gendered imagebased videobased media abuse harassment threats bullying cyber online deepfakes harm threats and synthetic these search terms were informed by the focus of the research which was to explore the harms experienced by women in technology and deepfakes the researchers selected search terms that were relevant to this topic and which could provide insight into the characteristics of threats brought forth by digital technologies and deepfakes for example the terms gendered imagebased and videobased were included to capture the specific types of deepfake content that are often used to harm women the terms abuse harassment threats and bullying were included to capture the various ways in which women can be harmed online the terms cyber online and media were included to capture the different types of platforms and technologies that are used to spread harmful content the terms deepfakes harm and synthetic were included to specifically capture content related to deepfakes and their potential harm to women by combining these search terms using boolean operators the researchers were able to generate a comprehensive list of articles that addressed the specific issues of interest data extraction should be relevant to the review question and thus results were further filtered according to the inclusion and exclusion criteria the inclusion criteria for this study included literature and articles that focused on technologys role in online abuse and women were written in english and published between 20012022 exclusion criteria for this study included nonenglish language articles articles not focused on technologys role in online abuse and women articles published before 2001 and articles that are not accessible to the researchers various terms were used to describe cyber abuse within the literature including cyberbullying victimisation and harassment thus cyber abuse was used as the superset term to reference intentional digital harm or threats or harassment or bullying or stalking through electronic and digital media through forms of media to which an individual feels uncomfortable threatened or abused eightyfive sources satisfied the inclusion and exclusion criteria and ten examined specific cases of five deepfake victims the data was collected and inputted in an excel matrix to be further examined coded for emergent themes and analysed through qualitative content analysis to identify the types of abuse and threats posed by digital technologies and deepfakes qualitative content analysis can be used as a data reduction method to identify fundamental patterns and interpretations that arise from text or images enabling researchers to gain a more scientific understanding of social reality qualitative content analysis aims to systematically convert larger quantities of data into highly organised and effective results following juntenen and lehenkari the researchers of this study began by reading and revising literature from the data collection next information relevant to the aim of this review was systematically extracted three analytical questions were developed as researchers read and discussed the literature together 1 what type of harm was inflicted by technology 2 how was this technology used and what was the impact 3 how has harm disrupted participatory onandoffline behaviours these questions aided in maintaining focus on the purpose of the review responses to the questions mentioned above were found across the literature and aided the synthesis of the research collection the data collected in the excel matrix were then reviewed for recurring inductive themes and presented in the following section lastly interpretation was conducted through abstraction based on discussions between the researchers on results related to other gendered cyberabuse research these interpretations are presented in the discussion section given the recent emergence of deepfake technologies and threats examining individual accounts there is the likelihood that the researchers did not observe literature that may have fit the studys selection criteria in the preliminary search some publications provided fragmentary insights into the theme and questions guiding the analysis only literature and media articles primarily focusing on the gendered issues related to cyber abuse deepfakes their characteristics and their harms were presented to preserve sources at a feasible quantity and increase the efficiency of the review process despite these limitations the researchers are confident this review is representative of the literature exploring gendered cyber abuse in the digital age literature review journal of digital life and learning 2023 vol 3 no 1 121 doi 1051357jdllv3i1218 5this literature review examines the harm women have experienced through technology and deepfakes this review begins with a brief introduction to cyber abuse of women next literature exploring imagebased sexual abuse in women is explored lastly deepfakes and related harm are presented willard defines abuse within cyberspace as the intent to consistently harass another to harm via any electronic method including social media and includes defamation public disclosure of private information and intentional emotional distress citron states threats of violence privacy invasions reputation harming lies calls for strangers to harm victims physically and technological attacks are volitional not simply innocuous commentary cyber abuse may manifest directly or indirectly direct cyber abuse may occur exclusively between the perpetrator and the victim in contrast indirect cyber abuse can occur when the perpetrator participates in the online space posting content about the victim in various social formats that are accessible to larger audiences within these contexts cyberabuse components include harassment repetition power differential and aggressionintention however some researchers do not consider the repetitive aspect as essential to the definition of cyber abuse cyber abuse in women abuse within cyberspace features unique qualities that magnify inflicted harm and make it increasingly difficult to detect the globalised nature of digital technologies allows malicious content to be created anonymously and circulated across the internet rapidly reaching global audiences more than half of victims do not know the identity of their perpetrator further contributing to increased fear distress and powerlessness in cyber victims compared to men women were three times more likely to face various forms of abuse online and more than two times more likely to experience severe forms of abuse eckert found that young women were significantly affected and the abuse had taken an emotionally significant toll barak states that gender harassment in cyberspace is very common through which cyber worlds become charged with diverse modes of abuse and violence against women feminist scholars have argued that cyber abuse echoes broader cultural and societal understandings presented within ones onandoffline worlds regarding gender and status nadim and fladmoe refer to gendered cyber abuse as offline misogyny evolving into social sectors according to jane gendered cyber abuse rests upon misogynistic practices that insist on womens inferiority inflicted abuse of women is an attempt to reassert the ordained power structures of men when they feel threatened by the loss of their relative position thus the act of abuse against women is intended to restore and reinforce differences between gender life and learning 2023 vol 3 no 1 121 doi 1051357jdllv3i1218 6sexism misogyny and abuse are apparent within cyberspace and new media forms can further exacerbate and complicate outcomes surrounding abuse and violence veletsianos et al indicated that identifying as a woman online increases the risk of intentional abuse the risk of cyber abuse is even greater for women in the public sphere or working within the digital space the most prominent forms of cyber abuse displayed and encountered by women were found to be slutshaming rape threats death threats and doxing in addition to the illpsychological symptoms and distress brought forth by cyber abuse women respond by selfcensoring their presence online and withdrawing from the digital world journal of digital amnesty international has investigated the effects of abuse against women on social media platforms specifically concerning how they act online after abusive incidents their study found that abuse created the silencing effect whereby women feel discouraged when participating online a report by gender women and democracy provides further illumination on the impacts silencing and censoring has on women victimised by online abuse stating by silencing and excluding the voices of women and other marginalized groups online harassment fundamentally challenges both womens political engagement and the integrity of the information space … in these circumstances women judge that the costs and danger of participation outweigh the benefits and withdraw from or choose not to enter the political arena at all veragray argues that with online usage by women and the continual development of new tools for online social networking more significant instances of cyber abuse can occur victims of cyber abuse are often left fearful of their continued online use with limited opportunities to pursue justice for those wishing to pursue legal action victims may lose time and pay from work their reputation and their employability due to online posts the extent to which perpetrators persecute and damage women online infringe on their offline worlds threatening the safety of these victims within physical social psychological and financial sectors imagebased sexual abuse in women the discourse on technologys role in cyber abuse has primarily concentrated on imagebased sexual abuse or the exploitation of intimate content ibsa refers to the act or threat of distributing intimate content without the consent of the targeted individual while anyone can be the target of ibsa research suggests women are more likely to be victimised by ibsa whereas men are more commonly the perpetrators the most frequent forms of online creation and distribution are social media email and mobile messages henry and colleagues suggest that the growing concerns with ibsa and new technologies can be attributed to the ease with which harmful media journal of digital life and learning 2023 vol 3 no 1 121 doi 1051357jdllv3i1218 7can be generated shared and downloaded the permanence of generated content in online spaces and the variety of accessible software and tools across multiple platforms efforts to normalise and popularise ibsa can be traced back to 2010 with the creation of isanyoneupcom a website that showcased stolen and hacked pornographic media internet users were encouraged by the sites creator hunter moore and site viewers to anonymously submit nonconsensual content of women as well as share personal and identifying information following an influx of media attention and legal actions by victims hunter moore was prosecuted and found guilty of extortion and identity theft few largescale research studies have examined the dissemination and outcomes of ibsa yet more than 3000 websites are dedicated to the submission of nonconsensual sexual media content while these websites host images of women and sometimes men images of women are more commonly viewed commented on and shared the evidence on prevalence implies high levels of abuse and a gendered impact with recent advancements in modern digital technologies it is projected that nonconsensual sharing and threats will continue to increase due to the feasibility of new assaults specifically ai tools and deepfake applications make it easier for perpetrators to anonymously engage in abusive nonconsensual behaviour on various platforms without impunity for their actions isba victims are reported to have significant feelings of helplessness hopelessness psychological distress and social disruption bates reported that women victimised by ibsa suffered from trauma posttraumatic syndrome disorder anxiety depression feelings of loss of control impaired sense of self and difficulties developing trust in others women victims were more likely than men to report feelings of vulnerability and threats to overall safety suggesting that some forms of ibsa are related to stalking and violence threats to safety are further exacerbated as victims are easily identifiable through imagebased content and personal information posted online women victimised by ibsa can be contacted by onandoffline actors who may harass coerce further distribute or extort unless behavioural requests are met cyber sextortion is a part of a larger continuum of ibsa which broadly refers to making threats to share explicit content online to garner a victims compliance with specific demands demands are varied and are not always sexual content is used to leverage control over victims and the perpetrators power to possibly harm victims is central to this crime perpetrators of cyber sextortion garner the victims images in various ways but most commonly online through manipulation or coercion cyber sextortion is unique to other forms of abuse as it is ambiguous whether the images will be shared which gives rise to fear and desperation in targeted victims life and learning 2023 vol 3 no 1 121 doi 1051357jdllv3i1218 8while sextortion is used to control the targets behaviour digital technologies and software have improved how the perpetrators commit these crimes motivations and methodology underpinning sextortion are associated with intimate partner violence violence against women cybercrime and exploitation acar suggests three primary differences between cyber sextortion and other crimes cyber sextortion is exclusively online the perpetrator is in possession of threatening content and victims are forced into acts through threats to distribute content journal of digital most ibsa victims prefer to stay unidentified which results in a lack of public attention on issues related to cyber abuse due to fear of personal safety and key figures being alerted victims are forced to withdraw from online spaces disclose the incident to employers change contact information and move physical locations and jobs as a result many victims have reported losing relationships with family friends and romantic partners in some cases victims may refuse to disclose threats due to shame and victim blaming as women are commonly blamed for the content produced hence while the impact of media distribution is significant its outcomes are emotionally harmful particularly with the loss of close social networks deepfakes and women the availability of technological devices has resulted in substantial growth of multimedia content in cyberspace leading to increased content production and greater accessibility recently digital impersonation has become more realistic and convincing jane argues that women have traditionally been the primary victims of nefarious adaptations in media and online content while deepfake technology has been put to a wide range of benign uses the technology has also been deployed to abuse debase and humiliate women victimised by ibsa widely overlooked in public debate deepfakes offer a new way to exercise domination and power as effective weapons of abuse deepfakes are most often deployed to compromise a womans identity inflict damage on her reputation intimidate and enforce silence by using a womans face and body as a digital resource in the absence of consent the distribution of deepfakes further presumes breeds and reinforces an online space in which womens images are forged for the overall pleasure of men who occupy these digital worlds of the nearly 85000 deepfakes circulating online 96 depict nonconsensual and sexually explicit content featuring women for example the online application deepnude uses gans to create natural looking depictions of nude womens bodies over 104000 fake nudes of women have been created and shared without the consent of victims many of whom were under 18 years old few women who have been targeted likely know that their deepfakes exist often there is very little that can be done even when deepfakes are known to victims the prevalence of deepfakes and the limited recourse available to victims journal of digital life and learning 2023 vol 3 no 1 121 doi 1051357jdllv3i1218 9is a complex issue rooted in several factors one primary challenge is the nascent nature of laws and regulations pertaining to deepfakes which may not be sufficiently comprehensive or effective in providing adequate legal protection or avenues for redress moreover the anonymity of deepfake creators who often distribute manipulated content through anonymous or fake accounts poses significant challenges in identifying and holding them accountable compounding this difficulty is the persistent nature of deepfakes once they have been widely disseminated as they can be readily replicated and circulated through multiple online channels including social media and messaging applications thereby exacerbating the challenges of mitigation and control in 2018 pseudonymous users circulated a viral deepfake sex video featuring rana ayyub an indian investigative journalist after she had made political comments regarding the child rape of a kashmiri girl deepfake videos were distributed among various social media platforms alongside her home address phone number and the phrase i am available her twitter and facebook feed were overwhelmed with screenshots of the video alongside death and rape threats the video was further popularised when a member of the bharatiya janata party quote tweeted the fake content and responded with wth what the hell are you out of your mind giving the fake content further legitimacy to twitter users despite calls for protection at national and international levels ayyub continued receiving obscene deepfake videos that attempted to slut shame her in an article detailing her experiences ayyub stated that she now practices selfcensorship has withdrawn from various digital spaces and fears people taking pictures of her as they may be used to create more deepfakes internet users can efficiently conceive deepfake videos subjecting targets to violent and humiliating sex acts although not all deepfakes will be designed for the creators sexual gratification the technosocial landscape of online environments provides deepfakes with the capability to incite reputational damage in 2019 a doctored video of us speaker of the house nancy pelosi was circulated on social media which made it appear as though she was drunk and slurring her words the video was shared widely leading to concerns about pelosis health and fitness for office chesney and citron note that deepfakes can be created merely to inflict fear pain and silence on women participating in public and private spaces deepfakes depict women partaking in nonconsensual activities without ever having engaged in them inciting abuse on those who do not want the attention and do not have adequate resources to address these fabrications in turn the effects of deepfakes on women can have social professional and personal ramifications for example noelle martins face and personal information were used to create deepfake pornographic content when she was a high school student she faced death threats rape threats extortion stalking and unwanted sexual advances as a result although she sought help from authorities and journal of digital life and learning 2023 vol 3 no 1 121 doi 1051357jdllv3i1218 10government agencies there was no resolution the deepfake attacks had a lasting impact on her social life law school prospects and comfort in public settings significant psychological distress has been observed when victims discover their media content has been deepfaked reporting feelings of humiliation violation fear helplessness and powerlessness research has found that victims of deepfakes and ibsa suffered from psychoaffective harm onlineandoffline harassment mental health issues suicidal ideation damaged professional and character reputations and personal and physical violation despite never participating in the observed actions in 2019 british poet and novelist helen mort had her images superimposed onto a series of deepfakes on pornographic websites these deepfakes appeared to have shown mort engaging in extreme acts of sexual violence she reported recurrent nightmares in which these images replayed themselves repeatedly and was incredibly anxious about leaving the house the threats of sexual violence literally albeit not physically penetrates the body citron suggests that deepfake videos force women into nonconsensual activities dehumanising them to mere objects of gratification for victims these videos can transform virtual threats into terrifying and physical realities and to online users within cyberspace it suggests that women can be abused at whim strong stigma is attributed to womens bodies and actions so deepfake victims are forced to suffer the collateral consequences and reputational damage invoked by their perpetrators discussion and recommendations cyber abuse is rooted in unequal powers of control resources and social rules that seek to preserve a mans dominance over their female counterpart despite their recent emergence deepfakes have become an effective tool in inflicting genderbased cyberabuse eroding a womens autonomy through shame humiliation and extortion while the harm from deepfakes is related to those found in ibsa victims this study has highlighted the unique harms for women that are felt both at individual and systemic levels the gendered nature of deepfakes especially when sexual in design must not be minimised the nature of deepfakes fosters opportunities for nefarious actions as perpetrators can easily superimpose a womans face onto another individual without the victim having ever committed the act depicted in the image or video often women are shown engaged in humiliating acts threatening their reputation safety and offline worlds the inflicted harm is magnified when deepfake content is anonymously created and shared across various internet platforms allowing audiences to rewatch download and distribute findings suggest that using deepfakes to perpetuate abuse follows the underlying themes of power control and sexuality the creation and use of deepfakes can represent a perception of regaining control or what can be described as compensatory manhood acts on individual levels targeted women of deepfakes may experience fear psychological and social maladjustments mental health issues reputational sabotage and face longlasting social professional and economic consequences deepfake abuse may rupture their lives their sense of self and identity and their abilities to form healthy relationships with themselves and others for some the harm and abuse may seem relentless and constant whereby victims live each day in fear of having their images or deepfakes discovered once uploaded deepfake content becomes extremely difficult to remove from the internet permanently the availability and dissemination of this content become another iteration of abuse as this is out of the control of victims they are rendered powerless further contributing to and magnifying feelings of helplessness and hopelessness the use of deepfakes challenges traditional claims and knowledge hierarchies it thrives on tactics that have been historically used to sabotage womens claims of truth and justice as the impacts of deepfakes carry an insurmountable impact on their targets women may involuntarily withdraw from their onandoffline worlds and be silenced the silencing effect observed by victims further contributes to a profound sense of seclusion and mistrust at micro meso and macrolevels this is concerning as online harms often target women finding their voices and building their identities online and offline the lack of recognition and extent of deepfake harm may be a form of disquisitional injustice for victims deepfake abuse fortifies issues related to gender disparities and preserves discriminatory practices that erode womens sovereignty and human rights deepfakes operate to discredit victims of their truth and draw from correspondence and coherence theories of truth to advance their credibility first ai technologies make deepfakes look real and correspond with the viewers observed reality second deepfakes cohere with assumptions about womens sexual availability within this framing discussion about fake porn appears to concretise existing trust flows and heighten distrust towards women thus the expected cyber abuse provides accountability when speaking out women become vulnerable to further abuse that endangers their physical safety this automated distribution and silencing contribute to the normalisation of this type of harm ayyub 2018chesney citron 2019acitron 2019 authors

as deepfake technologies become more sophisticated and accessible to the broader online community their use puts women participating in digital spaces at increased risk of experiencing violence online and abuse in a posttruth era the ability to discern what is real and what is fake allows malevolent actors to manipulate public opinion or ruin the social reputation of individuals to wider audiences while the scholarly research on the topic is sparse this study explored the harm women have experienced in technology and deepfakes results of the study suggest that deepfakes are a relatively new method to deploy genderbased violence and erode womens autonomy in their onandoffline world this study highlights the unique harms for women that are felt on both an individual and systemic level and the necessity for further inquiry into online harm through deepfakes and victims experiences

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introduction background youth assigned male at birth who have male sexual partners including young cisgender men who have sex with men young transgender women and gender nonconforming youth face substantial economic and health disparities in particular hiv risk and infection among ymsm ytw and gnc youth remains a significant public health problem in the united states ymsm ytw and gnc youth experience high rates of hiv infection 12 in 2017 17 of all new hiv diagnoses were attributed to maletomale sexual contact among adolescents and young adults aged 13 to 24 years 1 additionally 75 of adolescent and young adult hiv diagnoses were among black and latinx individuals 1 epidemiological hiv estimates for transgender populations are limited due to a lack of existing data however a metaanalysis of us studies involving trans women found an average hiv prevalence rate of 14 across studies that included laboratory testing 2 in this metaanalysis prevalence rates were higher among black trans women at 44 2 however these disparities cannot be understood solely in the context of individuallevel risk behavior given that there are multiple social and structural factors that increase risk for hiv exposure and acquisition among ymsm ytw and gnc youth of color 3 4 5 6 7 8 9 10 despite advancements in lesbian gay bisexual transgender and queer rights lgbtq people face persistent stigma discrimination and victimization in school the workplace housing and health care 11 12 13 14 such inequities are met with limited legal protections as few state laws specifically protect lbgtq people the consequences of this discrimination and lack of protections may be particularly pronounced for lgbtq people of color who face intersectional forms of discrimination and structural marginalization a high proportion of ymsm ytw and gnc youth of color live in poverty experience high rates of homelessness unemployment and violence and have limited access to hiv and other health and human services 14 15 16 17 18 19 20 furthermore these experiences of social and economic marginalization contribute to increased risk for hiv exposure and infection through their impacts on social determinants of health as well as coping and survival behaviors 14 15 16 1820 in particular financial insecurity and socioeconomic disconnection may increase engagement with survival sex work or sex in exchange for money drugs food and housing among ymsm ytw and gnc youth of color 21 22 23 engagement with survival sex work can place these individuals at heightened risk for hiv and sexully transmitted diseases by increasing exposure to higher prevalence sexual networks increasing their number of sexual partners and presenting challenges to negotiating condom use 21 22 23 structurallevel interventions have the potential to increase agency in members of marginalized groups and can facilitate healthpositive actions that benefit the individual and the community 24 often focused on distal drivers of poor health structurallevel interventions can promote uptake of healthpositive behaviors and improve access to healthpromotive environments 2425 given the ways that economic instability may place ymsm ytw and gnc youth of color at higher risk for hiv acquisition structural intervention to promote economic stability may serve to allow these youth to enact healthpromoting behaviors accordingly employment as prevention has the potential to be a scalable intervention that can be deployed among this group phase 1 of this study has already been published 26 rationale for employment as hiv prevention faced with few economic options and protections ymsm ytw and gnc youth of color may migrate to nontraditional economies or unregulated work as a means of survival in a study conducted by adolescent medicine trials network for hivaids interventions members in los angeles and chicago 76 of 151 ytw aged 15 to 24 years reported engaging in sex work with 35 in the past 3 months 5 among hivpositive ytw of color living in washington dc 23 were involved in sex workunderscoring the link between adolescent and young adult sex work and hiv exposure 27 in a large us study of ymsm roughly 12 reported engaging in sex work in the past 6 months 28 sex work and hiv risk are further complicated by drug and alcohol abuse 16 in order to effectively target economic stability as a route toward reducing hiv risk there is an acute need for scalable lowcost but potentially high impact structurallevel interventions that address the distal drivers of economic marginalization and adolescent and young adult hiv infection 24252930 the objective of the work2prevent study is to adapt and pilottest increased individual income and independence an effective theoretically driven employment program for hivpositive adults 31 32 33 34 to the needs of vulnerable ymsm ytw and gnc youth of color aged 16 to 24 years theoretical framework the ifour intervention draws on the theoretical framework of the health belief model 35 a widely used expectancy value model of health behavior change and the conceptual framework of supported employment a model in which individuals with physical or intellectual disabilities or impairments mental health issues or chronic conditions are assisted with identifying their own capabilities and obtaining employment 3637 the objective of the ifour intervention is to help hivpositive individuals identify barriers to obtaining employment increase the perceived benefits of employment and assess perceptions of the severity of their illness in order to increase behavioral intentions and selfefficacy for employment further ifour participants gain the tools and skills needed to effectively seek secure and maintain employment and increase economic independence and stability 31 32 33 34 in order to adapt and tailor the ifour intervention to the needs of adolescents and young adults of color the intervention draws on positive youth development in which young people understand value and develop external and internal assets such as community support empowerment to act clear boundaries constructive use of time commitment to learning positive selfconcept and social and emotional competency 38 39 40 pyd approaches orient young people toward future goals develop the skills necessary to engage youth in realworld roles and activities and build or fortify young peoples relationships with social networks 40 pyd builds from resiliency research in assuming that all youth are capable of achieving positive health outcomes despite challenges they may face in their environment 38 the adapted intervention will draw on pyd to provide the support relationshipbuilding skills and increased social and emotional competency shown to help youth succeed in employment methods conceptual model the w2p conceptual model shown in figure 1 draws on the existing ifour theoretical framework to hypothesize the potential relationship between adolescent and young adult employment and hiv risk the w2p model proposes that employment and subsequent economic connection and stability serve as a structurallevel intervention for hiv prevention among adolescents and young adults the hypothesis is that the adapted and tailored ifour intervention will facilitate increased job selfefficacy and job readiness and ultimately increase employment placement and maintenance further establishing economic stability will decrease engagement in hiv risk behaviors increase hiv prevention and care and decrease involvement with known social determinants of hiv such as sex work and substance use which are directly linked to hiv transmission and acquisition among ymsm ytw and gnc youth of color study design w2p uses a mixedmethods design phase 1 involves the adaptation of relevant intervention components from the existing evidencebased ifour employment program for hivpositive adults 31 32 33 34 to ymsm ytw and gnc youth of color phase 2 the topic of this paper consists of pretesting the intervention and study assessments and then running a singlearm pilot test of the adapted intervention to assess feasibility and acceptability with ymsm ytw and gnc youth of color as well as provide preliminary estimates of efficacy using prepost comparisons ethics consent and institutional board approval w2p has been reviewed and approved by the university of chicago institutional review board irb informed consent for this study is obtained in person by study staff before any studyrelated activities take place participants and study setting study participants include up to 75 black or african american and hispanic or latinx ymsm ytw and gnc youth inclusion criteria include being assigned male at birth reporting ever having sex with men identifying as african american or black or hispanic or latinx aged 16 to 24 years selfreport hiv negative or unknown status englishspeaking recruitment planned participant recruitment efforts include the distribution and posting of printed materials such as flyers hand bills and branded merchandise online postings on websites and social media such as facebook and twitter advertisements such as chicago transit authority posters and chats through the mobile app jackd study staff will also actively recruit from primary clinics serving ymsm ytw and gnc youth such as howard brown health during their youth dropin programs and at local gathering places and events frequented by the target population such as night clubs lgbtq centers house ball events black pride events pride fest and community outreach hiv testing events interested participants complete a prescreen survey to assess eligibility all interested participants are contacted and informed whether they are eligible eligible and interested participants are scheduled for baseline study visits visit schedule and data collection w2p consists of data collection across 3 time points at baseline postintervention and 8month postintervention as referenced in table 1 a 4session intervention workshop series occurs between the first and second time points incentives study participants are offered compensation for their time pretest participants may receive up to us 260 total while pilottest participants may receive up to us 330 total for complete participation participants will receive us 30 for each study visit completed at baseline postintervention and 8month followup up to us 40 for biological specimens at baseline and 8month followup if provided and us 40 for each workshop session attended payment is provided in the form of cash or visa gift card equivalent pretest up to 5 participants will be recruited for a pretest of the baseline study visit the 4session workshop series and the postintervention study visit pretest participants will not complete the followup assessment the purpose of the pretest is to give study staff an opportunity to familiarize themselves with the study visit procedures and workshop curriculum the pretest will also allow staff to determine if any final adjustments to procedures study instruments or the curriculum are needed prior to full rollout of the pilot testing participants who enroll in the pretest are not eligible to participate in the phase 2 pilot baseline participants will complete informed consent confirm eligibility and then complete an audio computerassisted selfinterview survey using an ipad survey items include questions pertaining to demographics sexual behaviors hivrisk behaviors relationships employment income substance use and other structural variables such as homelessness food insecurity and health care use optional biologic samples will be collected from participants who consent to them these samples include a finger stick for rapid hiv testing using the determine hiv12 agab combo a urine sample for drug screening chlamydia and gonorrhea testing and anal and oral swabs for chlamydia and gonorrhea testing intervention participants complete a 4session intervention workshop adapted from the existing ifour program 31 32 33 session 1 focuses on goal setting and identifying strengths session 2 on communication networking and job searching session 3 on balancing work with health and wellness and session 4 on preparing job application materials and interview preparation this adaptation of the curriculum was informed by interviews and focus groups with the target population as well as feedback from a youth advisory board the protocol for conducting interviews and focus groups is published elsewhere 26 workshops sessions are delivered by two facilitators in groups of 6 to 12 participants across the course of 2 weeks with 2 sessions per week the w2p career readiness workbook is used as a guide for all workshop sessions and is given to all study participants at the first session facilitators use an annotated w2p facilitator guide that provides detailed instruction on delivery of the intervention curriculum during each session facilitators complete a fidelity assessment to help ensure fidelity to the w2p career readiness workbook and after each session complete a workshop debriefing form to capture any workshop notes or comments postintervention once participants complete the workshop sessions participants complete a postintervention acasi survey using an ipad survey items include questions on workshop evaluation jobseeking selfefficacy and prep and hiv testing use month 8 followup the final study visit occurs 8 months after the intervention has been completed during this visit participants complete the baseline acasi survey using an ipad and provide repeat biologic samples if they consented to them outcomes primary outcomes information systems success model score the information systems success model will be used to assess for intervention acceptability and satisfaction the 21item scale yields a total score and measures 4 subdomains information quality handbook quality perceived usefulness and overall satisfaction this scale has been adapted from horvath et al 41 workshop completion workshop completion will be used to assess intervention feasibility workshop or intervention completion is defined as having attended at least 2 of the 4 workshop sessions and is measured by tracking participant attendance change in jobseeking selfefficacy scale score jobseeking selfefficacy is defined as ones perceived ability and confidence to perform job search and application activities the 12item jobseeking selfefficacy scale by barlow et al 42 yields a total score where higher values indicate higher selfefficacy jobseeking selfefficacy has been found to be associated with employment in a previous study of transgender women of color 29 change in protean career attitudes scale score protean career attitudes are defined as having selfdirection in the pursuit of success in ones work pcas have previously been found to be associated with positive career satisfaction and selfperceived success 43 the validated 7item scale by porter et al 44 yields a total score and measures 2 subdomains selfdirected attitudes and valuesdriven attitudes secondary outcomes change in selfreported hours worked per week hours worked per week is selfreported at baseline and at the 8month followup visit change in hours worked per week from the baseline to the 8month followup will be used to assess change in employment status change in selfreported sexual risk behaviors sexual risk behaviors are defined as selfreported engagement in the following behaviors during the previous 6 months 45 • condomless anal intercourse with cisgender male partner of unknown hiv status the previous 6 months refers to the 6 months prior to the baseline visit for the first assessment and the 6 months prior to the 8month followup visit for the second assessment change in sexual risk behaviors will be defined as the change in selfreported behaviors from baseline to the 8month followup change in chlamydia test result prevalence of chlamydia infections will be assessed at baseline and 8month followup using oral anal and urine samples each of the 3 tests yields a positive or negative result change in chlamydia test result will be defined as the change from baseline to the 8month followup oral anal and urine tests are treated as separate outcomes change in gonorrhea test result prevalence of gonorrhea infections will be assessed at baseline and 8month followup using oral anal and urine samples each of the 3 tests yields a positive or negative result change in gonorrhea test result will be defined as the change from baseline to the 8month followup oral anal and urine tests are treated as separate outcomes reactive hiv test testing for reactive or nonreactive hiv will be assessed at baseline and 8month followup the reactive hiv test outcome uses the 8month followup result power given the exploratory nature of this study and limited access to this population the analyses are not designed to have a specified level of statistical power a repeated measures pre and post design is used to reduce the variability in the estimate of the treatment effect statistical analysis descriptive statistics will be used to analyze the proportions and central tendencies for participant sociodemographic characteristics collected in the surveys we will first generate frequencies means and other measures of central tendency as appropriate to describe our sample and outcomes at each of the 3 time points baseline postintervention and 8month followup all participants who are enrolled at baseline and complete the baseline acasi will be included in the primary and secondary analyses as applicable analysis population participants will be included in all primary and secondary analyses for which their data for the specified outcome are not missing participants who do not attend any workshop sessions will not be included in analyses involving workshop evaluation primary analyses will assess intervention acceptability satisfaction and feasibility as well as change in jobseeking selfefficacy and pca score secondary analyses will evaluate the intervention by comparing employment and sexual risk behaviors preand postintervention changes in primary and secondary outcomes between baseline and 8month followup will be assessed using paired t tests for continuous variables and the mcnemar test for matched categorical variables we will use standard diagnostic tools to assess the appropriateness of the normality assumption and if approximate normality of the residuals is not tenable a nonparametric test for continuous paired data will be used all hypothesis testing will be performed at an alpha level of 010 given the exploratory nature of the study to the extent that data allows multivariable analyses will adjust for sociodemographic characteristics workshop attendance baseline employment status and study completeness analytical models will include linear regression or generalized linear models for continuous outcomes and logistic regression for binary outcomes analysis of the primary and secondary outcomes are described in detail within the statistical analysis plan which will be accessible on clinicaltrialsgov once study results have been entered results phase 2 w2p research activities began in march 2018 and were completed in november 2019 overall 5 participants were enrolled in the pretest and 51 participants were enrolled in the pilot discussion the goal of this project is to pilottest w2p a structurallevel employment intervention for ymsm ytw and gnc youth of color interventions that address the social and structural drivers of hiv exposure and infection are sorely needed in order to successfully bend the curve in the adolescent and young adult hiv epidemic although important for hiv prevention few individual interventions consider the complex ecological factors that make ymsm ytw and gnc youth of color vulnerable to hiv thus engagement with individuallevel interventions such as prep adherence and consistent condom use may be impeded by broader issues such as homelessness unemployment and survival sex work addressing these factors is an important first step in mitigating risk for adolescent and young adult hiv although employment is an important target for increasing economic stability and decreasing reliance on nontraditional economies such as survival sex work one limitation of this protocol may be that an immediate individual reduction of hiv exposure may not be detectable often structurallevel interventions rely on measurement of predictive outcomes that ultimately have downstream effects on health outcomes to address this challenge the study focuses on measures of job readiness jobseeking selfefficacy and career readiness as the strongest predictors of employment engagement and employability followup occurs at 8 months postintervention allowing participants time to enact skills and behaviors gained from the employment intervention additionally there is a potential limitation that the results of the intervention may not be generalizable beyond urban ymsm ytw and gnc youth of color as both the formative phase and intervention tailoring and refinement focused on the needs of this population subsequent adaptation and refinement may be necessary to engage youth outside of this target population if w2p demonstrates feasibility and acceptability among ymsm ytw and gnc youth of color in this pilot study we plan to test the efficacy of the intervention in a multicity longitudinal trial across the atn study sites if w2p demonstrates efficacy this intervention will provide vulnerable youth a tailored youthfocused way to gain employment and lifebased skills necessary to achieve economic stability and ultimately reduce the propensity for hiv exposure and infection clinicaltrialsgov nct03313310 author avs affiliation is included for informational purposes only this work was not conducted under the auspices of the guttmacher institute the views expressed herein are those of the authors and do not necessarily reflect the views of the guttmacher institute conflicts of interest none declared multimedia appendix 1

background young cisgender men who have sex with men ymsm young transgender women ytw and gender nonconforming gnc youth of color face substantial economic and health disparities in particular hiv risk and infection among these groups remains a significant public health issue in 2017 17 of all new hiv diagnoses were attributed to maletomale sexual contact among adolescents and young adults aged 13 to 24 years however such disparities cannot be attributed to individuallevel factors alone but rather are situated within larger social and structural contexts that marginalize and predispose ymsm ytw and gnc youth of color to increased hiv exposure addressing social and structural risk factors requires intervention on distal drivers of hiv risk including employment and economic stability the work2prevent w2p study aims to target economic stability through job readiness and employment as a structurallevel intervention for preventing adolescent and young adult hiv among black and latinx ymsm ytw and gnc youth this study seeks to assess intervention feasibility and acceptability in the target populations and determine preliminary efficacy of the intervention to increase employment and reduce sexual risk behaviors objective the goal of the research is to pilottest a tailored theoretically informed employment intervention program among ymsm ytw and gnc youth of color this intervention was adapted from increased individual income and independence an existing evidencebased employment program for hivpositive adults during phase 1 of the w2p studythe employment intervention will be pilottested among vulnerable ymsm ytw and gnc youth of color in a singlearm prepost trial to assess feasibility acceptability and preliminary estimates of efficacy

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introduction exposure to potentially traumatic events postmigration challenges and other psychological stressors can place conflictaffected populations at an increased risk of common mental disorders such as depression anxiety and posttraumatic stress disorder among displaced and conflictaffected populations the world health organization estimates the agestandardised prevalence of depression to be 108 anxiety disorders 217 and ptsd alone 153 these estimates are considerably higher than who estimates for common mental disorders among the general global population at 44 for depression and 36 for anxiety disorders included among those at risk are persons affected by the war in syria with an estimated 131 million requiring humanitarian assistance within syria itself and a further 56 million displaced across europe and neighbouring countries evidence from these settings signals elevated levels of common mental disorders among displaced syrian refugees the majority of the available evidence comes from adult populations with prevalence estimates ranging from 14 to 44 for depression 13 to 36 for anxiety and 11 to 83 for ptsd evidence among syrian children is more limited although findings consistently demonstrate symptoms of common mental disorders the majority of these studies focus on ptsd with prevalence estimates ranging from 33 to 50 an estimated 36 million displaced syrians live in turkey of whom almost half are children and adolescents under the age of 18 one study conducted in islahiye camp near the syria border found that exposure to traumatic events and common mental disorders was high among syrian children the majority had experienced a family member dying and 58 had experienced a stressful life event in which they believed their life was in danger nearly half of children in this study were found to have symptoms of ptsd and 20 were identified as having a depressive disorder of these significantly more girls than boys reported symptoms of depression the majority of syrians in turkey do not live in refugee camps but rather live among the host population this includes 550 000 syrians currently living in istanbul a survey among adult syrian refugees living in sultanbeyli district of istanbul conducted in 2018 found a high prevalence of depression anxiety and ptsd with the majority screening positive for these conditions not seeking care of any kind however data were not collected for children to the best of our knowledge just one study has previously been conducted with syrian children living among the host population in istanbul with common mental disorders found to be common half of the children surveyed scored above the clinical cutoff for ptsd with 24 judged to have very high general mental health problems however this was a schoolbased study and communitybased surveys are lacking epidemiological data identifying prevalence and factors associated with increased risk of common mental disorders are important for informing the development of public mental health policy special education and psychosocial support initiatives and programming for syrian children living among the host population in turkey the objectives of the current study are to estimate the prevalence of symptoms of common mental disorders among syrian refugee children living in sultanbeyli district of istanbul and identify associations between symptoms of common mental disorders and sociodemographic characteristics methods study design and sampling this crosssectional study was conducted between august and october 2019 in sultanbeyli district istanbul as part of an allage populationbased survey of disability among syrian refugees aged 2 years this paper reports specifically on mental health data collected among children and adolescents aged 817 years based on evidence from similar populations the prevalence of common mental disorders among children and adolescents aged 817 years was estimated to be 15 incorporating precision of 20 around the estimates 95 confidence 20 nonresponse and a design effect of 17 we required a sample size of 1073 participants aged 817 years the total sample size calculated for the allage survey of disability was 4000 the local municipalitys database of registered syrian refugees provided the sampling frame from which we selected the study population using a twostage sampling technique first we randomly selected 80 clusters of 50 participants each using probability proportionate to size sampling a cluster was defined as a single street within sultanbeyli district within each cluster we randomly selected households until at least 50 participants were included when a single street did not contain 50 participants we randomly selected additional households from randomly selected connecting and adjacent streets until the target number was reached across all 80 clusters enumerators visited households doortodoor tallying participants until at least 50 people were included for this survey all syrians within selected households were included in the survey regardless of their legal temporary protection status to maximise the response rate enumerators telephoned households in advance where possible to inform them of the survey purpose and arrange a suitable time to visit if unavailable enumerators attempted to revisit the household at another time including evenings and weekends survey questionnaires upon consent from the head of each household enumerators completed a household roster gathering sociodemographic information symptoms of common mental disorders were subsequently assessed in each child aged 817 years using direct selfreport questionnaires depression was assessed using the center for epidemiologic studies depression scale for children anxiety using the screen for child anxiety related disorders and ptsd using the child revised impact of event scale each of these tools has been previously used in research with refugee populations to limit the response burden we used abbreviated versions of the cesdc and scared validated for use with syrian refugee children living in lebanon each of these screening tools results in a total score indicating high or low symptomology these tools are designed to screen symptomology not to provide a diagnosis which is typically done through a clinical interview with a trained mental health specialist screening tools of this kind have typically been validated against clinical interviews and the cutoff scores indicate the level at which a child is likely to receive a diagnosis center for epidemiologic studies depression scale for children the cesdc measures the frequency and duration of symptoms associated with depression in children and adolescents this measure has been adapted to an abbreviated 10item version by queen mary university and their research partners for use with syrian children in lebanon the 10item version showed good internal consistency and was used in this study after consultation with the research team at queen mary university this abbreviated version asks children to respond to statements across a fourpoint likert scale identifying to what extent they experienced a given feeling in the past month screen for child anxiety related disorders the scared screens children and adolescents for anxiety disorders including general anxiety disorder panic disorder and separation anxiety disorder we used the abbreviated version developed by queen mary university previously validated for use with syrian children in lebanon and found to have good internal consistency the abbreviated measure used in this study scored the 18 items across a threepoint scale not true or hardly ever true somewhat true or sometimes true very true or often true the validated cutoff of 12 from a maximum score of 36 indicates symptomatic anxiety child revised impact of event scale the cries tool is designed to assess symptoms of ptsd the eightitem version demonstrates good psychometric properties among conflictaffected populations and has been previously used with syrian refugee children in turkey among refugee minors in sweden internal consistency was found to be acceptable the tool is designed to measure the intrusion and avoidance of unwanted thoughts feelings and memories and items are scored on a fourpoint scale not at all rarely sometimes often items ask children to report how frequently comments were true for them in the past 7 days when thinking about a stressful life event from a maximum score of 40 the cutoff of 17 indicates symptomatic ptsd child youth and resilience measure in addition to an assessment of symptoms of common mental disorders we also assessed resilience in children aged 1217 years using a modified 12item version of the cyrm which has been validated for use with syrian adolescents internal consistency was found acceptable in this validation study using this tool children are asked to rate the extent to which a statement is relevant to them on a fourpoint scale not at all a little somewhat quite a bit higher scores indicate a higher level of personal resilience as a protective factor against the onset of mental distress with a maximum score of 48 existing arabic versions of each tool were independently backtranslated into english assessing accuracy conceptual equivalence and cultural acceptance these tools were subsequently piloted with members of the target population by technical experts who shared recommendations of minor amendments for use with this population data collection enumerators administered each of the selfreport questionnaires directly with a child within their home if requested a parentguardiancaregiver remained present throughout the interview enumerators conducted the interview in arabic visual aids were used to help children understand the questionnaire responses each of the enumerators had completed a 10day training covering the aims of the survey interview techniques mental health and disability sensitisation data entry procedures and ethical responsibilities data were collected on android tablets using the london school of hygiene tropical medicines open data kit software collected data were encrypted and uploaded to a secure cloudbased server at the end of each day data analysis data were analysed using stata version 140 prevalence estimates were calculated from those children scoring at or above the cutoff on each measurement tool these estimates were stratified by age sex and socioeconomic status the svv command in stata was used to account for the cluster sampling methods principal components analysis was used to derive a socioeconomic index from household level indicators such as household asset ownership type of residence and source of heating the resulting socioeconomic score was divided into quartiles from the poorest to least poor the first principal component accounted for 1496 of the variation in the original data multivariate regression analyses were undertaken to assess the relationship between each common mental disorder and individual household level and sociodemographic characteristics informed written consent was sought from the selfidentified head of each household prior to completion of the household roster and collection of demographic information informed consent was subsequently sought from parents and caregivers for children and adolescents aged 817 years verbal assent was also sought from the children and adolescents ethical approval results study population of 1080 eligible participants aged 817 years 852 took part in the survey 157 were unavailable and 71 refused the sample characteristics of these participants are provided in table 1 of the study sample 439 were female and 413 male compared to participants nonparticipants were on average slightly older and more likely to be male overall the sample age distribution was largely comparable to the registration database used for the sampling frame with slight underrepresentation of older children on average participants in the study had been displaced from syria approximately 4 years prior to the study the vast majority of children lived in a flatapartment or house in terms of the highest education level attained 73 had attended primary school 20 had attended secondary school and 6 had never attended formal education prevalence of common mental disorders the estimated prevalence of symptomatic depression anxiety and ptsd were 125 92 and 115 respectively overall 237 had symptoms of one or more of these common mental disorders as seen in table 3 164 screened positive for symptoms of just one condition only 53 showed symptoms across two conditions and 21 were found to have symptoms of all three common mental disorders association with resilience children with symptoms of depression demonstrated significantly lower mean resilience scores compared to children without symptomatic depression as shown in table 4 there was no association observed between resilience score and symptoms of anxiety or ptsd association with sociodemographic variables table 5 presents the association between each common mental disorder and sociodemographic variables adjusted for age and sex older children were three times more likely to experience symptomatic depression 36 95 ci 2168 and ptsd compared to younger children although this association was not observed for anxiety symptomatic anxiety and ptsd were more common among girls with no association observed for depression demonstrating symptoms of these common mental disorders was not significantly associated with the number of years since leaving syria symptomatic depression was more common in children who had received no education although no association was seen for ptsd or anxiety symptomatic ptsd was found to be significantly less likely to occur in children living in a household with 8 members compared to those living in households of 24 household size was not associated with symptomology of depression or anxiety and the sex of the head of the household was not associated with any common mental disorder symptomatic depression was slightly more common among children who lived in the poorest households although this was of borderline significance socioeconomic status was not associated with either ptsd or anxiety discussion this study reports on the prevalence and sociodemographic predictors of common mental disorders among syrian children living in istanbul nearly a quarter of children screened positive for symptoms of at least one common mental disorder by condition 125 screened positive for symptomatic depression 92 for anxiety and 115 ptsd older children were more likely to screen positive for symptomatic depression and ptsd with girls more likely to screen positive for anxiety and ptsd depression was more common among children who had received no education and were from the poorest households these estimates fall at the lower end of prevalence figures identified in a recent systematic review of studies among young refugees displaced across europe in which estimates ranged from 103328 for depression 19527 for ptsd and 87316 for anxiety our findings on ptsd do however align with evidence from an umbrella review conducted by turrini et al which identified five surveys of 260 refugee children that generated an estimate of 11 for ptsd similar to that in our study the wide variation in these estimates may reflect the varying study and sampling methodologies and the different screening tools as well as the different characteristics of the refugee groups and host communities overall our study indicates a substantial burden of common mental disorders among syrian children in istanbul with nearly a quarter of children demonstrating symptoms of at least one common mental disorder our estimates are considerably higher than estimates from the who for the general population and are congruent with the evidence of a substantial burden of common mental disorders among syrian refugees eruyar et als study among syrian school children in istanbul estimated the prevalence of ptsd to be 50 using cries8 the same screening tool used in our study this estimate is considerably higher than that identified in our study although their sample was recruited from two syrian schools only limiting the comparison to our communitybased survey similarly the prevalence of ptsd was estimated to be higher among children living in islahiye camp in southeastern turkey this study also utilised the cries8 with 45 of children reaching the cutoff for symptomatic ptsd further 44 screened positive for depression of whom 20 reached the clinical cutoff albeit via a different screening tool to that used in our study comparison between these estimates and ours may reflect a greater risk of common mental disorders among those refugees living in a camp setting compared to those living in an urban setting among the host population as with our sample additionally the study in islahiye camp was conducted in 2012 just one year after the start of the war in syria and the study in syrian schools was conducted in 2015 in contrast 75 of children in our 2019 study had been away from syria for at least 4 years and the difference in ptsd estimates may indicate that children with more recent exposure to the war and associated trauma are at a higher risk of symptoms of ptsd our study identified a number of risk and protective factors associated with common mental disorders among syrian children in istanbul children with symptomatic depression in our sample were more likely to come from poorer households consistent with evidence on the social determinants of mental health among the 1113 117 95 103 1417 206 ± 97 183 ± sex male 111 48 92 female 139 132 ± 137 ± ± significant at p 005 epidemiology and psychiatric sciences general and refugee populations symptoms of depression were also more common in children who had not attended school school is crucial to a childs integration and acculturation in the host community providing children with a place in which to develop relationships and a sense of belonging evidence indicates that the social support structures provided by a school offer protection against common mental disorders although the mechanism of this among syrian children in istanbul merits further investigation similar structures may explain our finding that children from households with a larger number of household members were significantly less likely to demonstrate symptoms of ptsd social support is a strong protective factor for common mental disorders and children from larger households may receive more stable social support shielding them against symptoms of ptsd this is consistent with the intervention pyramid proposed in the interagency standing committee guidelines on mental health and psychosocial support in emergency settings which highlights the need for strengthened community and family supports for those affected by situations of emergency displacement and conflict as was expected symptomatic depression was inversely associated with resilience scores consistent with panterbrick et als study among syrian youth this association was not however observed for symptoms of anxiety or ptsd despite support from the literature on the role of resilience as a protective factor against the onset of these disorders further exploration is required in the interaction of resilience with social factors among syrian children living in istanbul important to consider among our findings is the higher prevalence of common mental disorders in girls compared to boys this is consistent with research from across refugee and general populations in which girls are reported to have a higher prevalence of depression and suicidal ideationattempts than boys gender differences in anxiety and ptsd are less well defined but apparent in some studies this includes our study in which girls demonstrated a significantly higher prevalence of symptomatic anxiety compared to boys evidence suggests that girls are more likely to exhibit internationalising behaviours as opposed to externalising behaviours in boys particularly in adolescence males and females also exhibit differences in helpseeking coping strategies and preferences for treatment these are important considerations for future prevention and intervention strategies for this population limitations this was the first populationbased survey of common mental disorders in syrian refugee children living among the host community in istanbul survey teams visited participants in their households which may have contributed to the higher response rate than a previous study of adult mental health in the same district however there were some limitations firstly the sample was selected from the sultanbeyli municipalitys refugee registration database which does not include information of unregistered or undocumented refugees who may have a higher prevalence of common mental disorders we sought to address this to some extent by including all eligible syrians within a household regardless of legal refugee status but this cannot account for those unregistered households who would have been missed during the first stages of sampling second the response rate was slightly lower than 80 although age and sex distribution were largely congruent with the registration database third all efforts were made to interview participants in private but this was not always possible as interviews were conducted in the childs home and caregivers had the right to be present this may have resulted in response bias especially with the sensitive nature of questions on mental health arguably considering the stigma often attached to mental health this may have resulted in underestimates of common mental disorders the number of participants interviewed in the presence of caregivers was not recorded which would have aided further analysis fourth a clinical diagnostic interview would have resulted in more precise prevalence estimates but this was not feasible within a population survey selfreport mental health screening tools can result in overestimated prevalence figures although this is an issue common to nearly all other studies finally we used abbreviated versions of tools used to assess symptoms of depression and anxiety the tools and cutoffs for these abbreviated versions have been validated with syrian children living in refugee camps in lebanon as opposed to children living among a host population as is the case in sultanbeyli these validated cutoffs may be higher than needed for children in sultanbeyli as children living in camps may be more likely to endorse certain items given more challenging living conditions as such our estimates for symptomatic depression and anxiety in children may represent an underestimate similarly the tool used to assess symptoms of ptsd has been validated among arabic speaking and refugee populations but not among syrians specifically conclusion we have presented findings of the first populationbased study to report on the estimated prevalence of symptomatic depression anxiety and ptsd among syrian children and adolescents living in istanbul turkey nearly 25 of participants demonstrated symptoms of at least one common mental disorder the estimates of this study are considerably higher than in the general population and represent a substantial burden of these common mental disorders in this population with high estimates of common mental disorders among syrian children in istanbul it is important to support mental health intervention and prevention policies and programmes for this group data for more information on the data supporting the findings of this study please contact nathaniel scherer all participants were under the age of 18 and parent or caregiver consent was obtained for each participant verbal assent was sought from the participant themselves using a simplified information sheet appendix 1 visual aid for use with scared measurement tool epidemiology and psychiatric sciences

prevalence of common mental disorders among syrian refugee children and adolescents in sultanbeyli district istanbul results of a populationbased survey

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background in 2019 229 million new malaria cases and 409000 deaths occurred worldwide with 94 of cases and 94 of the deaths occurring in africa 1 the gains made this century against malaria have plateaued and the disease continues to kill a child every 2 min malaria is responsible for an unacceptable number of hospital admissions and outpatient visits and greatly contributes to poverty in most subsaharan african regions 1 despite the progress made in malaria control the disease remains the leading cause of morbidity and mortality in burkina faso and is endemic with a peak during the rainy season 23 according to the annual national health report 2018 malaria was responsible for 615 of hospitalizations and 305 of deaths in the country and an estimated 11 million uncomplicated malaria cases 2 at the primary health facilities 604 of admissions and 40 of deaths were associated with malaria especially in children under five years of age 2 to address the malaria burden in burkina faso the national health authorities have implemented several programmes and malariacontrol strategies at health facility and community levels these include accurate malaria diagnosis and prompt treatment of uncomplicated cases the introduction in 2016 of a free healthcare policy for pregnant women and children under five years of age 4 and a recommendation to use artemisininbased combinations therapy this class of medicines was adopted and classified as firstand secondline treatments of malaria since2005 and updated in 2017 communitybased interventions are also being implemented eg community case management of malaria since 2010 and the seasonal malaria chemoprevention strategy since 2014 targeting children aged between 3 and 59 months 3 current efforts to further control and eliminate malaria greatly depend on the perceptions adherence and acceptability of antimalarial interventions early careseeking behaviour associated with prompt diagnosis and treatment with act are key components to preventing a mild case of malaria from progressing into severe disease and death 3 5 6 7 8 several studies across african countries have investigated community careseeking practices and perceptions towards malaria as a disease 9 10 11 12 13 14 these concluded that most frequently seeking treatment is delayed and poor access to health care providers or caregivers lack of education and awareness of malaria symptoms 16 result in many febrile children not receiving adequate and prompt diagnosis and treatment in addition several studies have demonstrated that caregivers of children stop the malaria treatment with act prematurely upon resolution of initial symptoms 81516 given that local beliefs around disease also influence attitudes and adherence to malaria treatment the us presidents malaria initiative in collaboration with the nmcp has agreed that one programmes key performance indicator is that 100 of the population knows two methods to prevent malaria and another kpi is that 90 understand the need to seek treatment within 24 h of symptom onset 3 with the development of artemisinin resistance in southeast asia 17 18 19 20 and the risk of its spread to subsaharan africa 2122 malaria control strategies have to be adjusted and adapted thus optimising the use of current artemisininbased combinations still efficacious in burkina 2324 is crucial to extend the therapeutic life of artemisininbased combinations by reducing drug pressure and slowing down the spread of resistance 2526 the simultaneous use of multiple combinations as firstline therapy for malaria treatment has been suggested 2527 the communities use of health services associated with early careseeking plays an important role in the success and sustainability of any malaria control strategy 828 including multiple firstline treatments determinants of careseeking behaviours as well as practices and attitudes towards febrile episodes were assessed among community members in the hd of kaya in burkina faso to inform the implementation of the mft pilot programme methods study setting this study was conducted ahead of the mft pilot programme implementation between november 2018 and february 2019 the study was conducted in the hd of kaya located in the northcentral region 100 km from ouagadougou the capital city of burkina faso the hd of kaya is composed of four communes one urban and three rural with a population of about 407311 inhabitants in 2018 the district has 215 villages covering an area of 3617 km 2 and 40 public health facilities including 39 primary health care centres and one medical centre in 2018 there were four private and faithbased health facilities in kaya the regional hospital in kaya is the regions referral hospital in the hd of kaya 191771 uncomplicated malaria cases were recorded in 2018 with an incidence rate of 127 per personyear and 04 per personyear in children less than five years of age and the total population respectively 2 in the same year 983 of the malaria cases were treated by act study design and populations this was a communitybased crosssectional study with a mixedmethod design quantitative household survey a quantitative household survey was carried out using a structured questionnaire during the high malaria transmission season in november 2018 the questionnaires were administered to all individuals either directly or to their parentscaregivers in households having had a fever within the 28 days preceding the survey the subjects who had a fever in the household were categorized into four different groups children under five 5 to 15 years 16 to 45 years and pregnant women those subjects aged at least 18 years or emancipated minors were directly interviewed but if the subject having had fever was a minor the questionnaire was administered to their parents caregivers the respondent was a person who could provide accurate information about the febrile episode and fig 1 map of heath facilities in the hd of kaya its management thus a parentcaregiver was able to respond for more than one person in the household qualitative survey focus group discussions were conducted with community members the study populations included the head of household mothers of children under five years of age adult men pregnant women and community leaders they were selected for their role in the careseeking behaviours for suspected malaria episodes sample size and sampling strategy for the quantitative survey the study participants were selected through multistage sampling in the first stage ten public health centres were randomly selected from the list of health centres in the district in the second stage in each health facility two villages or sectors were randomly selected to participate in the survey in the last stage households were randomly selected within the selected villages to take part in the survey using a random walk method all individuals in a household having had a fever during the past four weeks were interviewed directly or interviews were done with their parents caregivers the sample size calculation is described elsewhere 27 briefly it was estimated at 408 with a confidence level of 95 and a desired power of 80 from each of the three target groups of population having had fever 27 pregnant women who have had fever were recruited during the survey at community level as long as the fieldworkers identified them assuming a rate of imponderables of 10 the estimated sample size was 450 participants with fever in each age group in addition fgds were conducted with community members who are potential beneficiaries of care participants were randomly and purposively recruited for fgds with the assistance of the heads of health centres first five specific groups in the community were identified to participate in the group discussions sessions heads of household mothers of children under 5 adult men pregnant women and community leaders for each identified group five health centres were randomly selected from the list of all health centres afterwards with the assistance of the head of the health centre participants were purposively identified and invited to take part in the discussion sessions sensitive to social and cultural issues men and women were not mixed in the same fgd session variables definition the outcome variables included prompt careseeking behaviour and careseeking at health centres the former was defined as seeking care within 24 h of fever onset the latter comprised visiting primary health centres medical centres the regional hospital and private clinic for fever within four weeks before the survey exploratory variables that could have a potential effect on populations careseeking behaviours ranged from sociodemographic factors accessibility to providers and the quality of services delivered by providers the sociodemographic factors of study participants included age gender residence area occupation education status and household size the accessibility factors were defined as the distance travelled for care cost accessibility and mode of transport to the health provider the services factors delivered by providers were categorized as good reputation of provider personal previous experience and availability of malaria medicines the quality of the services was established based on either the good reputation the previous positive experience in the same health facility and malaria medicines availability the management of febrile episodes at health centres was assessed through malaria rapid tests performed treatment received and adherence to medication reported by the population recruitment and data collection hd of kaya quantitative survey participants were interviewed in 1036 sample households of 19 randomly selected villages or sectors through facetoface interviews using a structured questionnaire twelve fieldworkers were recruited and trained during 3 days on the study procedures the questionnaire was pretested and administered over approximately 2030 min in french and mooré the most spoken languages of study participants the respondents interviewed were adults or emancipated minors when the patients age was less than 18 years the interview was conducted with parentscaregivers a household was defined as a family unit where the head of the household his spouse and other relatives live together and share their income data collected were related to sociodemographic status of participants which could influence the careseeking behaviours careseeking behaviours for febrile episode factors influencing careseeking behaviours and access to effective management of fevermalaria including treatment practices information on treatment practices was collected through selfreporting by study participants qualitative survey data were collected through 23 fgds conducted with community members to understand their knowledge on malaria disease attitudes and practices towards fevermalaria and its management the fgd guide was developed by the study social scientists pretested and administered to selected participants five social scientists with masters degrees were recruited and trained for 3 days they conducted the fgds in the village where participants lived at the residence of one participant or at the health centre each fgd included 710 participants and lasted for about 45 to 90 min the discussions were audiorecorded transcribed and translated into french by the social scientists for analysis the discussions were conducted in the local language using semistructured interview guides grouped in two sections the first section explored the communitys knowledge about malaria including its morbidity burden the second section was dedicated to patterns of careseeking behaviour data management and analysis after data collection quantitative data were entered by two data clerks using epidata and analysed with stata version 16 univariate descriptive analyses such as frequencies proportions means or median were used to describe sociodemographic characteristics of the study populations communities attitudes and practices regarding febrile episodes malaria and access to effective malaria case management including diagnosis and treatment chisquare and fishers exact tests were used to compare the proportions factors influencing careseeking behaviours including time taken to seek treatment and visiting health centres were explored through bivariate and multiple logistic regression the statistical significance was set at p 005 odds ratio and 95 confidence interval were used to measure the associations between the dependent and independent variables a variable with a pvalue of 020 or below in the tests of significance in the bivariate analyses was exported to the multivariate regression model likelihood ratio test was used to compare different models the final model was obtained by backward elimination and was assessed for its fitness to the data by the hosmerlemeshow goodness of fit test dataderived codes developed through deductive and inductive coding and retrieving was used during analysis for qualitative data indeed all transcripts were coded linebyline using preset themes further codes were added for emerging themes the qualitative data software programme nvivo was used to organize all qualitative data and prepare these for analysis ethical considerations ethical approval was obtained from the national health ethics committee of burkina faso the study purpose and procedures were explained in the local languages to potential participants by study staff upon explaining the objectives of the study written consent was obtained from all respondents and confidentiality was maintained all procedures followed were carried out per the helsinki declaration version 2013 fortaleza results sociodemographic characteristics of study participants the sociodemographic characteristics of the study participants are shown in table 2 a total of 1394 subjects who had fever within 28 days before the survey were interviewed during the household survey of which 577 were females onethird of subjects were less than five years of age and the proportion of pregnant women was 25 the mean age with standard deviation was 24 ± 12 years 85 ± 30 years and 276 ± 87 years for children under five years 515 years and participants 16 years and above respectively three quarters of households visited had more than six persons living in the household the majority of respondents 522 were the mothers of subjects with fever and 116 were fathers in total 69 of respondents had never been to school whereas 86 reported having secondary or higher education levels over three quarters were farmers followed by housewives and employees or merchants participants knowledge about malaria participants knowledge about malaria was explored through fgds most of the respondents had good knowledge about malaria symptoms prevention tools and effective treatment they knew that fever is the main symptom of malaria associated with other symptoms table 1 fgds conducted with communities members group identified number of fgds community key opinion leaders 5 heads of household 6 mothers of children under 5 5 pregnant women 4 adult men 3 total 23 when children have malaria their bodies get hot and they vomit adults also get hot and vomit then they say that he has weogo weogo is the local name of malaria that he has malaria there are also headaches vomiting participants agreed and recognized that malaria is transmitted by mosquitoes they believed the cause of malaria had changed over time as they said in the past it was said that it is food consumption that causes malaria but today this is not quite true it is only the mosquitoes and the unsanitary conditions that cause malaria so if mosquitoes can cause malaria it is when they bite a person who has malaria and when they bite another person they transmit malaria to that person some main preventive measures against malaria are well identified and known by the local populations in the hd of kaya they stated we sleep under bed nets which protects us from malaria in the families we use mosquito nets at night we also clean the houses and manage the wastewater well so that mosquitoes cannot proliferate insalubrity is favourable for mosquitoes careseeking behaviours of participants towards malaria as shown in health centres are by far the mostpreferred place to seek treatment but some participants explained that traditional healers and remaining familial drug stock are also used so far we do still use decoctions in addition to medicines and injections because this allows us to boost the modern medicine in the treatment of the patient we use acacia mango eucalyptus guava leaves for the decoction in my case when it happens fever i first look for paracetamol if it doesnt work i come to the health centre in families there are several categories of malaria so if someone goes to the dispensary once and is prescribed medication and gets well after the cure if another child is sick they take the remaining medicine again to give to this child who is sick malaria treatment practices reported by populations the table 4 shows the malaria treatment practices reported by the population almost three quarters of patients with fever were tested for malaria using a rapid diagnostic test of those tested 967 were positive for malaria for treatment received by patients having had a fever three quarters received act as an antimalarial drug almost all of malaria patients were treated with al and the adherence level to a treatment regimen with act was 843 factors associated with prompt careseeking table 5 shows the factors associated with prompt treatmentseeking using bivariate and multivariate analysis in the bivariate analysis distance travelled for care less than 5 km household size ≤ 6 people schooling were significantly associated with prompt treatmentseeking behaviours from the multiple logistic regression analysis distance from the provider schooling were found to be significantly associated with prompt treatment people living 5 km from the provider were 22 times more likely to seek treatment within 24 h of fever onset factors influencing careseeking at health centres bivariate and multivariate logistic regressions were performed to assess independent factors associated with the attendance at healthcentre providers as shown in table 6 from those who sought treatment at health centres geographical proximity to health centres having children under 5 or being pregnant women smaller household size and residence in an urban area significantly affect careseeking behaviours after adjusting on education level most of the participants went to health centres because of proximity in addition having a child under five being a pregnant woman living in an urban area household size less than 6 members were found to be statistically associated with visiting health centres for febrile episodes the bivariate analysis showed that the geographical proximity was not initially significantly associated with seeking treatment at a health facility during the fgd the main reasons for participants to seek care at health centres were described as geographical proximity belief that malaria is a hospitaltreated disease and availability of free medication for children under 5 whether it is in the morning or at night since the health centre is nearby you dont even hang around you will not see any more patients in the health centres here if there is no more free health care we see many children here because of the free health care before people were not aware of the seriousness of the disease now people are aware of it they run directly with the patient to the hospital in the case of malaria people run quickly to see a health worker and the result is that they immediately recover their health discussion this study was initiated before the implementation of the mft pilot programme as a new malaria treatment strategy in the hd of kaya to assess communities attitudes practices and determinants of careseeking behaviours for feversuspected malaria episode overall populations in the hd of kaya have a good attitude regarding careseeking behaviour for a febrile episode or suspected malaria they sought advice or treatment for the majority of febrile episodes most of the time within 24 h of fever onset and at health centres the proportions of populations seeking care for fever who promptly sought care and got treated at health centres were 98 665 and 768 respectively health centres were by far the first choice of care providers followed by chws selftreatment using the antimalarial drugs at home and traditional healers proximity to health centres good reputation of providers having a child under five being pregnant or residing in an urban area were significantly associated with careseeking at health centres while geographical proximity and education were identified as determinants of prompt careseeking within 24 h of fever onset in this study communities sought advice or treatment for almost all febrile episodes similar findings in careseeking for fever were previously reported 29 and the results are consistent with the rate of malaria careseeking reported by studies conducted in liberia 30 ethiopia 31 six african countries benin democratic republic of congo madagascar nigeria uganda and zambia 32 and laos 33 the higher appropriate careseeking behaviour rate in this study resulted partly from different efforts deployed in malaria control activities including community sensitization based on chws activities and social and behaviour change name of act received artemetherlumefantrine 313 adherence of duration of treatment with act communication these activities resulted in improving peoples knowledge of malaria disease which increased their willingness to take action after the onset of presumed malaria symptoms especially fever twothirds of the study population sought treatment within 24 h of fever onset proximity to the care provider was the main factor explaining this behaviour and practices the findings of this study are consistent with results reported in the previous studies elsewhere 34 35 36 however the proportion of people promptly seeking care in this study is higher than results found in studies conducted in equatorial guinea 37 and ethiopia 38 in those studies settings accessibility of providers was an issue and could have explained the lower proportion of prompt careseeking people living far from the provider are more likely to delay careseeking proximity to a health provider meant better accessibility to the provider which influenced careseeking within the 24 h of fever onset in line with burkina faso nmcps strategic plan that set the goal for at least 90 of the population knowing the advantages of receiving malaria treatment in the first 24 h of illness this careseeking behaviour is encouraging as it will prevent mild cases from becoming severe and hence reduce malariarelated mortality the level of prompt treatmentseeking in this study could also be explained by the communities good knowledge about malaria reported during the fgds in addition several studies showed that prompt treatmentseeking within 24 h of fever onset is strongly linked to the knowledge of malaria 313839 to manage febrile episodes people in the community choose providers differently in this study health centres were the preferable providers for those seeking care for fever the findings revealed that about threequarters of study participants used healthcentre services as the first point of call for treatment similar results were reported elsewhere 313340 people recognize that malaria is fatal if appropriate treatment is not given on time to explore factors influencing the use of healthcentre services multivariate logistic regression was performed proximity to health centres having children under five being pregnant or residing in in urban areas were significantly associated with careseeking at health centres geographical proximity is a wellestablished strong predictor of attending health centres and was widely demonstrated in many studies 33 41 42 43 this study showed the same result people living far from health centres are less likely to seek treatment at those facilities in this study the mean distance from participants residences to health centres was 35 km this reflects the availability of health centres in the study area and might explain the higher number of people attending health centres for advice or treatment the behaviour preference to seek treatment at health centres is also associated with the location of residence in this study populations living in urban areas are more likely to seek treatment at health centres for fever than those in rural areas similar findings were reported in other studies conducted in subsaharan african these findings suggest that people living in urban areas are more likely to have higher levels of educationschooling which could increase their knowledge about malaria and have an impact on their willingness to use the healthcentre services parents having children under five and pregnant women are more likely to seek treatment at health centres compared to other age groups the recent lifting of treatment fees for children under 5 and pregnant women and the sensitization of mothers of children through smc delivery in burkina faso may explain our findings the results are consistent with studies reporting that abolition of user fees for children under five increases the probability that caregivers would take them to health centres in case of febrile illness 64546 indeed during the fgds the access to free care for children was one of the main reasons given by caregivers for visiting health centres and was associated with an increase in the number of consultations at health centres artemetherlumefantrine was used in the majority of all treatments with act given to febrile patients this finding is in line with the nmcp guideline for malaria case management at public health centres and the community level in burkina faso 47 al is the most recommended firstline therapy for malaria and the most available drug at public health centres and with chws in addition this finding revealed the higher pressure on al by using it to treat all patients with malaria overall adherence to the act regimen was 845 the adherence level is consistent with other studies conducted in burkina faso 48 tanzania 49 kenya 50 this level of adherence is acceptable and could be attributed to the effect of the efforts of the malaria control programme nevertheless 155 of patients were not adherent to the full threeday regimens of al the consequences of inappropriate lowdose use of act especially nonadherence to a treatment regimen associated with the permanent use of the same drug for malaria treatment can lead to selecting artemisinin drug resistance 51 the findings reported in this study should be considered along the following limitations and strengths this study used a mixedmethod design to collect data which can be considered a strength the qualitative part complemented the quantitative findingsduring the fgd populations described in their own words their careseeking behaviour the summary of findings was important to inform the implementation of mft pilot programme one of the limitations in this study is the 4week recall period used to collect information about the febrile episode that can lead to recall bias in addition data collected and presented here are selfreported which might be associated with social desirability bias the crosssectional design of our study did not allow us to explore a causal relationship conclusions this study conducted in the hd of kaya showed that a large majority of the population sought treatment at health centres within the 24 h of fever onset in addition adherence to the act regimen was high and almost all patients were treated with the same artemisininbased combination al these results combined with the good knowledge of malaria disease could potentially facilitate a successful implementation of the mft pilot programme which is based on activities at healthcentre level the mft programme could have significant benefits in fighting drug resistance by slowing the fixation of resistant strains and retarding selection pressure to the partner drugs used in artemisinin combinations in tandem continuous effort will be needed to sustain the populations awareness of effective malaria case management and their prompt treatmentseeking behaviour upon onset of suspected malaria symptoms abbreviations act artemisininbased combination therapy al artemetherlumefantrine chws community health workers fgd focus group discussion hd health district kpi key performance indicator mft multiple firstline therapies nmcp national malaria control programme rdt rapid diagnostic test who world health organization 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

background malaria case management relies on world health organization who recommended artemisininbased combination therapy act and a continuous understanding of local community knowledge attitudes and practices may be a great support for the success of malaria disease control efforts in this context this study aimed to identify potential facilitators or barriers at the community level to inform a health districtwide implementation of multiple firstline therapies mft as a new strategy for uncomplicated malaria case managementa communitybased crosssectional study using a mixedmethod design was carried out from november 2018 to february 2019 in the health district hd of kaya in burkina faso quantitative data were collected using a standardized questionnaire from 1394 individuals who had fevermalaria episodes four weeks prior to the survey in addition 23 focus group discussions fgds were conducted targeting various segments of the community logistic regression models were used to assess the predictors of community careseeking behaviours results overall 98 13661394 of study participants sought advice or treatment and 665 did so within 24 h of fever onset 764 of participants preferred to seek treatment from health centres as the first recourse to care 58 were treated at home with remaining drug stock and 23 preferred traditional healers artemetherlumefantrine al was by far the most used antimalarial drug 982 reported adherence to the 3day treatment regimen was 843 multivariate analysis identified less than 5 km distance travelled for care aor 27 95 ci 2137 and educationschooling aor 18 95 ci 1325 as determinants of prompt careseeking for fever geographical proximity aor 15 95 ci 1221 having a child under five aor 46 95 ci 3267 being pregnant aor 65 95 ci

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introduction bali province is one of the tourist destination areas with a fairly high number of tourist arrivals both from domestic tourists and foreign tourists according to data from the bali provincial statistics agency there were 478198 foreign tourist visits in june 2023 this figure increased by 881 percent from may 2023 meanwhile based on data from the bali province tourism office domestic tourist visits were recorded at 883793 visits seeing the increasing number of tourist visits many souvenir companies have developed in the area around the tourist attraction such as in badung regency areas such as kuta jimbaran and nusa dua denpasar city to gianyar regency the tourism sector in bali has risen again after being hit by the covid19 outbreak since then the rise of the economy in bali province has been driven by the tourism sector one of which is through the souvenir industry this can be seen from the increasing data on tourist visits souvenir companies that sell their products through souvenir shops are usually present around tourist sites with the aim of meeting the needs of souvenirs for tourists the souvenir products sold are used as a memento of the area or tourist location bali has souvenir companies scattered in almost all tourist attractions some of the most popular souvenir companies in bali province are krisna the basket bali agung bali dewata and many other souvenir companies these souvenir companies generally sell a variety of souvenir products made by craftsmen from various regions in bali the popularity of souvenir companies especially in bali province cannot be separated from the visual identity or logo used a souvenir company must have something that can stick in the minds of its consumers something that can be recognized understood and remembered easily the use of a logo as a means of identification and can shape and grow the companys image in the minds of consumers through this image a logo can be a public consideration in choosing a souvenir shop to shop for the desired souvenir products in addition to conveying the value of the company a logo can also be used to attract consumers if the company is a souvenir company the logo used should be in the form of images of souvenir products sold or bring up something visually distinctive from the area by using existing local wisdom it will be an interesting thing this includes one of the identification functions of the logo where the audience can identify what the company is engaged in and what it produces likewise in bali province which is rich in culture this is also contained in the regional regulation of the province of bali number 4 of 2020 concerning strengthening and promoting balinese culture article 19 it is explained that the utilization of cultural promotion objects can be carried out through socioeconomic activities so the use of local elements as a form of cultural promotion in the visual elements of the company logo also needs to be done especially for souvenir companies a logo can be understood as a series of words or images that represent a company institution or individual in a symbolic way corporate identity is seen as a tool and asset used to take advantage of opportunities to build brand awareness increase recognition a means of communicating uniqueness and quality and as a differentiator with similar companies if for a company the identity of a company reflects the vision and mission of a company which is reflected in the company logo a logo is often a mainstay in shaping the image of a company so that the strength and image are attached to the community so the logo will always be displayed in every part of the company such as uniforms stationery promotional media and other company assets visual elements that form a logo can be in the form of shapes colors typography and illustrations currently most souvenir companies especially in bali province have used logos as their corporate identity with various visual styles used however it is not yet known what visual elements are used by souvenir companies in bali province in their logos and it is not yet known whether the logos contain balinese identity there have been many studies that discuss logos the research discusses visual elements as logo strength formers written by made arini hanindharputri and aa sagung intan pradnyanita which discusses the visual elements that form the strength of a logo then the research entitled designing a logo by abdul azis said which discusses the things that need to be considered in designing a logo however research on visual elements in souvenir company logos especially in bali province has not been found it is hoped that this research can add knowledge contribute thoughts about the logo of a typical regional souvenir company method the descriptive method is used with the aim of describing or describing the state of the logo as the object of research based on visible facts and as it is descriptive research method is the right method for this research because the method can be used to describe the object of research observed in more depth real and detailed the use of descriptive method in this research is expected to achieve the goal of providing an objective description of the content of balinese identity in the logos of souvenir companies in bali province through analyzing the visual elements in the logos the object of research is the logo of the keranjang bali dewata and agung bali souvenir companies the research object was chosen based on data of popular companies in bali province the data collection techniques used are interviews observations and literature studies obtaining data through collection techniques is a fundamental way of research the data analysis stage uses the miles and huberman interactive data analysis stage with three stages namely data reduction data presentation and conclusion drawing at the data reduction stage it is done by sorting the data from interviews observations and literature studies data from interviews with logo experts collected were then summarized data from direct and online observations were also sorted and narrowed down to logo data from popular souvenir companies that sell various balinese souvenir products after being reduced the data is then presented in the form of charts and tables and then analyzed to find what visual elements are used to form the logos of souvenir companies in bali province figure 1 data analysis technique result and discussion the analysis of the research object consists of the classification of logos of souvenir companies in bali province based on the type of logo and analysis based on the visual elements that form the logo classification of logos of souvenir companies in bali province based on logo types classification of logos based on logo types is done to examine the types of logos used by souvenir companies in bali province referring to the types of logos according to john murphy and michael rowe different types of logos were found in the logos of souvenir shop companies in bali province as follows 1 name only logo a type of logo that takes a company name using a special graphic style this type of logo is also referred to as a name only logo or logotype 2 pictorial name logo this type of logo uses the company or product name as an important element of the logo style and overall this type of logo has a distinctive style 3 allusive logo allusive logos or representation logos are logos that are figurative in nature this type of logo has an indirect relationship between the company name and the logo making it quite difficult to understand • the keranjang bali logo included in the name only logo logo type sans serif typeface there is the word bali as the identity of bali all capital letters with enlargement in the middle to give a clear contemporary and memorable impression • dewata oleholeh khas bali logo belongs to the figure ground logo type there is a balinese dancer object in the letter d there is meru in the letter w and there is the word bali as the identity of bali and a butterfly • agung bali logo belongs to the allusive logo type contains an icon as the identity of bali there is a cartoon of a young man with balinese udeng and cambodian flower as the typical balinese flower in conclusion of the analysis above it is found that the gift shop companies each use three types of logos and contain balinese identities consisting of balinese text balinese dancers meru frangipani flowersjepun and cartoon youth with udeng logo analysis based on the visual elements of the logo was conducted to examine the visual elements of balinese identity used in the logos of souvenir companies in bali province these visual elements include shape color typography and illustration the analysis of the logo elements of souvenir companies in bali province can be seen in the tables 4 5 and 6 the keranjang bali table 4 logo element analysis of the keranjang bali souvenir company image description shape the overall shape of the logo is rectangular in the logo the shape consists of a logotype with the layout of the placement of the words the placed at the top with a smaller size then the placement of the words keranjang bali is located below the words the with a larger size and there is an enlargement effect in the middle of the text this is to emphasize the company name so that it is easily remembered by the audience who sees it and gives a simpler and more modern impression the content of balinese identity on the form is the content of bali text color the color used is green green is included in the traditional balinese color nawa sanggha and has a meaning of fertility the content of balinese identity is in the green color as part of the nawa sanggha color tipografi the typeface used belongs to the scripthandwriting category with a thin or light letter weight then the text is also printed in uppercase letters as a whole or all caps this is intended so that the logo can be read clearly by anyone and at any distance but also still presents a simple and modern impression the content of balinese identity in typography is the content of bali text dewata oleholeh khas bali image description shape the overall shape of the logo is rectangular the shape consists of a pictorial name logo type with the layout of the placement of the words dewata placed at the top with a larger size then the placement of the words oleh oleh khas bali is located below the writing dewata with a smaller size the writing by the typical by is given a separate rectangular box from the writing bali this is to emphasize the name dewata so that it is easily remembered by the audience who sees it the content of balinese identity in the form is in the text dewata dancers meru and bali color the colors used in the logo are red black white and yellow the colors red black yellow and white are the traditional balinese colors tri kono tri kono is the concept of the phases of human life namely birth life death the meaning of this color contains balinese spiritual values regarding death to the afterlife the content of balinese identity in color is in red black yellow and white as the color of tri kono typography the typeface categories used in the logo are sans serif and script sans serif is used in the words dewata and typical souvenirs while script is used in the words bali the use of sans serif type depicts a modern nonrigid and attractive impression sans serif typeface also has a high level of readability while the script typeface used is able to give an elegant natural and feminine impression the content of balinese identity in typography is in the text dewata and bali ilustration the illustrations contained in the logo consist of illustrations of traditional dancers on the letter d in the word dewata illustrations of meru contained in the letter w illustrations of butterflies located at the end of the word bali illustration of balinese dancers meru shape and butterfly shape balinese dance is a sacred dance the shape of the dancer on the logo is like a legong dance with a single dancer intended for religious events and cannot be separated from the culture of hindu palace and hindu dharma ilustration in the company logo there are no illustration elements found because the company logo is included in the name only logo type which means it is only in the form of writing or logotype illustration of meru meru is one of the sacred buildings of hindus that is very majestic magnificent and monumental the roof shape is tumpang roof meru is a temple building in immanent religious appreciation tugu panglurah is the palinggih of the lurah the escort of the lord istadewata hyang widhi kupu kupu illustration in balinese hindu philosophy means enlightened creatures have a light soul beautiful heart the content of balinese identity in the illustration is in the illustration of dancers meru and butterflies rumah kaos oleholeh khas bali agung bali table 6 logo element analysis of agung bali tshirt souvenir house company image description shape the overall shape of the logo is ellipticaloval the shape consists of a type of allusive logo with the layout of the placement of the words agung bali placed in the center with a larger size then the placement of the words rumah kaos byh oleh khas bali is located above the words agung bali with a smaller size and surrounds half the elliptical shape frangipani flowers and a cartoon drawing of a young man with a headband below the words agung bali there is also bali writing between the illustrations the content of balinese identity in the form is in the text khas bali bali frangipani flowers and cartoon youth with a headband color the colors used in the logo are red black and white red black and white are traditional balinese colors tri kono tri kono is the concept of the phases of human life namely birth life death the meaning of this color contains balinese spiritual values regarding death to the afterlife the content of balinese identity in color is in red black and white as the color of tri kono typography the font type used in the logo design of agung bali gift shop is also included in the script writing category the use of this type of font on the logo gives the impression of modern free attractive has a strong character and can be read clearly then the typeface contained in the circle is a typeface that belongs to the sans serif category the typeface gives a firm impression but still looks simple and classy this can be attributed to emphasizing that the souvenir shop company sells a variety of tshirts and balinese souvenir products the content of balinese identity in typography is in the text khas bali and bali ilustration the illustrations in the logo consist of illustrations of frangipani flowers jepun flowers and along with cartoon illustrations of young people using udeng illustration of frangipanijepun flower and cartoon youth using udeng frangipanijepun flowers have an important role in hinduism namely as a symbol of lord shiva and as a means of prayer cambodia with white petals and a yellow tinge is the most widely used balinese identity because it contains the meaning of white and yellow colors balinese hindu belief the white color is a symbol of iswara who has the power like badjra which emits white light the yellow color is a symbol of mahadeva or lord shiva who has the power of nagapasa which emits yellow light udeng is one of the characteristics used by men udeng is a piece of cloth tied around the head with colorful shapes and patterns udeng for the temple must be white in order to create the impression of clarity of mind and peace of mind the content of balinese identity in the illustration is in the illustration of frangipani flowers and cartoons of young men with ikat the results of the logo classification analysis based on the visual elements of logo formers that contain balinese identity in tables 4 5 and 6 obtained the following data • the keranjang bali logo shape element rectangle with large main text keranjang bali the content of balinese identity is contained in the text bali color element green is the color of nawa sanggha the content of balinese identity is found in the color green typography element the typeface is scripthandwriting light the content of balinese identity is contained in the text bali illustration element no • dewata logo of balinese souvenirs shape element rectangle with large main text dewata the content of balinese identity is contained in the text dewata and bali color elements red black yellow and white are the colors of tri kono the content of balinese identity is found in red black yellow and white typography element the typeface is san serif scripthandwriting light the content of balinese identity is contained in the text dewata and bali illustration element there are illustrations of balinese dancers meru buildings and butterflies • logo of agung bali tshirt balinese souvenir house shape element ellipseoval with large main text agung bali the content of balinese identity is contained in the text bali color elements red black and white are the colors of tri kono the content of balinese identity is found in red black and white typography element the typeface is san serif scripthandwriting the content of balinese identity is contained in the text bali illustration element there are illustrations of frangipani flowers japanese flowers and cartoons of young people using udeng conclusion based on the results of the analysis the data obtained from the three logos of souvenir shop companies in bali province consists of the classification of logo types and analysis of the visual elements that make up the logo the keranjang bali logo including the name only logo type dewata logo of balinese souvenirs including the figure ground logo type agung bali logo including the allusive logo type the balinese identity found in the three logos of the balinese souvenir company is balinese text balinese dancers meru buildings butterflies frangipani flowers jepun and udeng the existence of colors and illustrations in logos such as balinese dancers meru buildings butterflies frangipani flowersjepun and udeng is not only a distinctive identity visually but also in meaning has a meaning that is closely related to the beliefs embraced by the majority of balinese people namely hinduism as described in tables 1 2 3 4 5 and 6 thus it is found that the three souvenir shop companies use balinese identity visually with the content of its meaning that adheres to hindu philosophy which is one of the platforms to utilize the object of promoting balinese culture as stated in the regional regulation of bali province number 4 of 2020 concerning strengthening and promoting balinese culture article 19

bali province is a very popular tourist island in indonesia everyone around the world can recognize bali because of its distinctiveness that is easily recognizable it becomes balis identity bali with its uniqueness makes bali with a province that has many visual identities these identities are important as the promotion of culture it is also stated in the regional regulation of bali province that the utilization of cultural promotion objects can be carried out through socioeconomic activities one of these utilizations is using balinese identity on elements in the social and economic fields as a place of tourism there are many souvenir shops in bali the souvenir shop companies in bali province use logos as their corporate identity but whether balinese identity is used on the logos of souvenir shop companies based on this this study aims to examine the visual elements in the logos of souvenir shop companies in bali province to find balinese identity this research uses a qualitative method the data sources used in this research are observation literature study and interviews observations were made of the logos of souvenir shop companies in bali province based on data analysis the logos have balinese identity including the name bali balinese color jepun flower udeng temple and legong dance the results of this research are expected to add and develop knowledge and serve as a reference for research on logos

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even more limited is research that extends a family systems approach to ethnic minority families given the significance of cultural values and experiences in shaping family dynamics findings from the literature on white families may not generalize to other sociocultural groups a cultural ecological perspective also directs attention to the substantial variability in family dynamics and youth adjustment that exists within a particular ethnic group and emphasizes the importance of ethnic homogeneous designs wherein the processes underlying within group variability can be illuminated researchers have generally ignored the substantial degree of variability in the circumstances of african americans instead focusing primarily on families in challenging circumstances for instance although nearly 40 of african american youth live with both parents most research includes only singlemother households when african american fathers are included the focus has primarily been on the implications of fathers residential status for youth development although fathers residency contributes to adolescent adjustment residing with a father does not necessarily imply strong father child bonds and more research is needed examining the implications of father adolescent relationship quality for youth outcomes building on family systems and cultural ecological tenets the goals of this study were to describe parent adolescent warmth and shared time as a function of parent and youth gender and assess links between these indices of relationship quality and adolescent internalizing and externalizing behavior including the moderating role of parent and adolescent gender and birth order in an effort to understand the potentially unique roles of mothers and fathers in their childrens adjustment we used data from a sample of twoparent african american families much of the prior literature on this topic has been subject to monoreporter biases which may be particularly problematic during adolescence thus in addition to its conceptual contributions this study improves on prior study designs by incorporating information from four family members finally this studys focus on the role of potentially modifiable family dynamics in youth adjustment may have important applied implications for youth and family prevention and intervention programs gender differences in parent adolescent relationship qualities research on white samples indicates that during adolescence youth begin to identify more strongly with their samegender parent and that the quality of this relationship has implications for their adjustment thus researchers have called for greater attention to the role of parent and child gender in research on family dynamics issues of gender may be particularly relevant for african american families a popularized notion holds that african american mothers raise their daughters by providing rules and discipline but love their sons by displaying warmth and permissiveness hill suggested that gendered differential treatment may occur because mothers heightened concerns for their sons safety and the barriers to success experienced by african american men manifest themselves in higher expectations for daughters and greater tolerance for sons misbehavior systematic data on african american parents gendered differential treatment of their children however are rare consistent with parenting in other racialethnic groups there is evidence that african american parents engage in more monitoring of daughters than sons in a study by hill and zimmerman african american mothers with chronically ill sons were found to treat their children more favorably than mothers with chronically ill daughters although these findings cannot be generalized to a healthy sample the authors suggested that small size and physical disability were viewed by mothers as more debilitating for boys than girls in the context of greater constraints on the adult roles of african american men finally mandara varner and richman found evidence of an interaction between youth gender and birth order for mothers behaviors compared to secondborn daughters secondborn sons had fewer responsibilities less cognitive stimulation and more mother child conflict in order to advance understanding of gendered differential treatment in african american families two methodological constraints of previous work in this area must be addressed first though it has been suggested that african american mothers are warmer toward sons than daughters but that fathers act in the opposite way few studies have actually examined differential treatment in twoparent african american families second empirical investigations into gender differences in african american parents treatment of offspring have largely relied on betweenfamily comparisons of parents with sons versus parents with daughters as family scholars have noted withinfamily comparisons of mothers versus fathers warmth toward their sons versus their daughters may better illuminate family gender dynamics accordingly given limitations in existing evidence we chose not to advance a specific hypothesis regarding african american parents warmth toward sons versus daughters in twoparent families while gendered differential treatment may be evident in these families it also may be that similar to european american families african american parents treatment of boys and girls does not differ significantly on the other hand consistent with past research on european americans and the role of mothers as kinkeepers across multiple ethnic groups we predicted that mothers would report warmer relationships with their children than fathers in addition to parental warmth we also examined gender differences in parents shared time with adolescents evidence from white families revealed that in the face of mothers overall higher level of involvement parents spend more time with samegender compared to oppositegender adolescent offspring our knowledge of african american parents time with offspring comes almost exclusively from studies of families with infants and young children results from this work suggest that african american parents involvement in child care largely mirrors that of their white counterpartsl although fathers were involved with their children they were less involved than mothers building on this work we used withinand betweenfamily comparisons to examine african american parents shared time with adolescents given findings about parents time with adolescents from white samples in conjunction with evidence that african american parents resemble white parents in the amount of time they spend with infants and young children we tested the predictions that mothers would spend more time with adolescent offspring than fathers and parents would spend more time with samegender offspring links between parent adolescent relationship qualities and adolescent adjustment research based primarily on white samples revealed clear links between parent adolescent relationship quality including parental warmth and involvement and adolescent adjustment although these associations are receiving more attention among african american parents and children much remains unknown about the adolescent adjustment implications of parent adolescent relationships particularly father adolescent relationships for racialethnic minority youth furthermore when racialethnic minority families have been considered there have been mixed findings with regard to gender with some work suggesting that associations between parent adolescent relationship quality and adolescent adjustment differ for mothers and fathers and their sons and daughters and some suggesting uniformity across parent and child gender research on parent adolescent relationship qualities and internalizing behaviors in african american families has largely been constrained to examination of one parent or to youth of one gender for example in a study of african american mothers bynum and kotchick found that youths reports of maternal relationship quality were positively related to their selfesteem and negatively related to their depressive symptoms focusing on african american fathers and daughters cooper determined that relationship quality was positively related to selfesteem using data from one primary caregiver and adolescents sagrestano paikoff holmbeck and fendrich provided compelling longitudinal evidence that positive parent adolescent relationships were related to fewer depressive symptoms in african american youth finally in a multiracial study of the effects of fathers residence booth scott and king found that close relationships with fathers were more influential for adolescents internalizing behavior than was family structure maternal relationship quality was controlled for but otherwise was not a focus of the research taken together these findings led us to predict that mother and fatheradolescent relationship warmth and shared time would be negatively related to internalizing symptoms fathers encouragement of autonomy in conjunction with their more peerlike relationships with their offspring are thought to facilitate the development of adolescents adjustment in the world beyond the family evidence supporting this theory in african american samples can be gleaned from work on the effects of father involvement for instance the greater risk of externalizing behavior seen in african american boys relative to girls is considerably lessened when fathers are present others have found father adolescent relationship quality in african american samples is protective against adolescents alcohol use the role of mother adolescent relationship quality in youth externalizing behaviors is less clear given this pattern of findings we tested the prediction that paternal warmth and shared time would be negatively associated with youths risky behavior and that these associations would be more consistent than those for mother adolescent relationships and youths risky behavior method participants the data came from mothers fathers and two adolescentage siblings in 134 families who participated in a study of african american family relationships families that selfidentified as african american or black included a mother and father figure and who lived together with at least two offspring were targeted for recruitment two strategies were used to generate the sample in two urban centers in the midatlantic region first african american community members recruited about half of the sample by advertising the study in their communities second families who had been identified using a purchased marketing list were sent letters describing the study and were asked to respond by postcard or tollfree number if they were eligible and interested given our interest in adolescent internalizing and externalizing outcomes we focused on wave three of the study when relevant measures were collected of the original 202 families participating in the first phase of the larger study 10 families in which one parent was not african american 8 coparents who were not in a couple relationship and 22 families in which parents divorced across the study period were omitted data were also unavailable for 9 families that withdrew and 10 fathers who did not participate additionally we omitted nine families with siblings age 20 or older of the 134 families in the present analyses mean ages of mothers and fathers were 4308 and 4563 respectively the majority of families included two or three children mothers education averaged 1479 years and fathers education 1435 years with a score of 12 signifying high school graduate 14 signifying some college and 16 signifying a bachelors degree given the high correlation between mothers and fathers education r 45 the mean was included as a control most parents were employed and worked fulltime hours family income averaged 9993186 with two families reporting no income for the past year and eight reporting incomes over 200000 with respect to couple relationships 14 couples had been cohabiting for at least two years and the rest had been married an average of 1648 years two adolescent siblings from each family also participated older adolescents averaged 1587 years and younger adolescents averaged 1248 years of age the majority were biologically related to mothers and fathers and the sample was approximately equally divided by gender and dyad gender constellation procedure two procedures were used for data collection first family members were interviewed individually in their homes by a team of two interviewers almost all of whom were african american family members reported on relationship experiences and personal characteristics during the past year interviews lasted about 2 hours for parents and 1 hour for adolescents following the completion of interviews families received a 200 honorarium the second data collection procedure was used to obtain information about adolescents daily activities in the month following the home interview seven telephone interviews were conducted during these calls youth reported on their daily activities outside of regular school hours the type of activity how long the activity lasted and with whom they had engaged in each activity calls were scheduled in the evening measures parent adolescent relationship warmth was reported by mothers and fathers using an 8item 5point rating scale from the parents version of the childs report of parental behavior inventory higher scores represented greater warmth and alphas ranged from 87 to 89 parent adolescent shared time was measured using adolescent reports from the seven nightly telephone interviews we aggregated youth reports across all activities and all seven calls to create a measure of the time that adolescents spent with their mothers and with their fathers depressive symptoms were measured using the childrens depression inventory for 26 items adolescents were asked to choose the statement that best described them over the past week items were summed with higher scores indicating more depressive symptoms alphas were 78 for older and 72 for younger adolescents risky behaviors were assessed using the 18item risky behavior scale older and younger adolescents reported on their involvement in risky behaviors using a scale of 1 to 4 items were summed with higher scores indicating more risky behavior alphas were 86 for older and 78 for younger adolescents results the results are organized by our aims to describe parent adolescent warmth and shared time as a function of parent and youth gender and to assess links between these indices of relationship quality and adolescent adjustment including the moderating role of parent and adolescent gender and birth order parent adolescent warmth shared time depressive symptoms and risky behavior were squareroot transformed in all models due to skewness given that youth age parents education and biological relatedness may be confounded with the independent variables they were controlled in the analyses withinfamily differences in parent adolescent relationship qualities parent adolescent relationship quality was assessed using 2 × 2 × 2 × 2 mixed model ancovas with parental warmth and parent youth shared time as dependent variables parent gender and sibling were withingroups factors sibling genders were betweengroups factors and parents education and adolescents age were entered as covariates biological status of children was tested as a covariate but was never significant and thus was removed from the final models means and standard deviations for study variables are presented in table 1 untransformed means suggested that parental warmth was quite high averaging greater than 4 on a 5point scale in all cases analyses revealed no significant differences in parentadolescent warmth as a function of older siblings gender younger siblings gender and gender constellation of the sibling dyad the sibling effect trended toward significance f 313 p 10 and there was a significant effect of parent gender f 413 p 05 as table 2 illustrates parents tended to report warmer relationships with younger relative to older offspring and mothers reported warmer relationships with adolescents than did fathers untransformed means for parent adolescent shared time revealed that mothers spent about 8 to 10 hours a week with adolescents and fathers spent about 6 to 7 hours a week with adolescents parent adolescent shared time did not differ as a function of older siblings gender younger siblings gender or gender constellation of the sibling dyad and here the withinfamily effects of parent and birth order also were nonsignificant two significant interactions emerged however between parent and older sibling gender f 411 p 05 and between parent and younger sibling gender f 758 p 01 to follow up these interactions two t tests were conducted to compare the difference between mothers and fathers time with older and with younger siblings as a function of adolescents gender these revealed that the difference between mothers and fathers time with youth was greater if the older sibling was girl compared to a boy t 445 p 001 the mother father difference was also greater when the younger sibling was a girl versus a boy t 456 p 001 positively signed means indicate that mothers spent more time with children than fathers on average but that this difference was pronounced when the family included a daughter and is suggestive of mothers gendertyped differential treatment of offspring differences between mothers and fathers time with sons and daughters were further qualified by 3way parent × birth order × older sibling gender f 2002 p 001 and parent × birth order × younger sibling gender f 1795 p 001 interactions to test the gender component of these interactions we conducted two t tests comparing mother father differences in time spent with older and younger siblings as a function of older and younger adolescents gender when the older sibling was a boy the difference between mothers time with the younger compared to the older sibling was greater than the difference between fathers time with the younger versus the older sibling further when the younger sibling was a girl the difference between mothers time with the younger compared to the older sibling was greater than the difference between fathers time with the younger versus the older sibling in both cases mothers as compared to fathers tendency to be less involved with older sons and more involved with younger daughters indicates interparental differental treatment of children associations between parent adolescent relationship qualities and adolescent adjustment to address our second aimexploring links between parent adolescent relationship qualities and adolescent depressive symptoms and risky behaviorwe used a multilevel modeling strategy this approach extends multiple regression to account for dependencies in the data in addition an mlm framework provides for the use of cases with missing data we tested separate twolevel random intercept models with family as the unit of analysis for the outcomes of depressive symptoms and risky behavior the level 1 model accounts for dependencies between members of the same family here we included withinfamily predictors that differed for older and younger siblings level 2 estimates including parents education and adolescents age are characteristics shared by youth in the same family but differ across families by including mothers fathers and older and younger sons and daughters in the same analyses we were able to test the moderating roles of parent and adolescent gender and birth order on relationshipadjustment linkages in the case of significant interactions by gender to test the slopes we reran the same models treating girls and older siblings as the reference group parent education and offspring age were included as controls in all models beginning with depressive symptoms main effects indicated that girls trended toward higher depressive symptoms than boys but that there was no effect of birth order this analysis also revealed that maternal warmth was negatively associated with adolescent reports of depressive symptoms neither fathers warmth nor mothers or fathers shared time with adolescents was related to adolescents depressive symptoms turning to risky behavior boys engaged in risky behavior more frequently than girls additionally adolescent age was positively related to risky behavior findings also showed that paternal warmth and shared time were negatively related to adolescents risky behavior maternal warmth was significantly and negatively related to risky behavior but this effect was qualified by gender followup tests revealed that maternal warmth was unrelated to daughters risky behavior β 88 se 356 t 25 ns but negatively related to sons β 1042 se 378 t 276 p 05 mothers shared time with adolescents was unrelated to their risky behavior and there were no interactions involving gender or birth order discussion responding to the call for research on normative processes in african american families this study explored parent adolescent relationship qualities and their associations with adolescent adjustment in twoparent families the design of this study was in keeping with a key tenet from the cultural ecological perspective on the importance of illuminating factors that explain the substantial withingroup variability in minority youths adjustment finally our research addressed the popularized notion that african american mothers are warmer with sons and that in twoparent families fathers work to balance this pattern regarding differences in parental warmth results revealed no evidence that either mothers or fathers differed in their levels of warmth toward sons versus daughters although these findings suggest that african american parents love did not differ based on adolescent gender two issues deserve consideration first this study did not investigate rules or expectations about responsibilities or behavior stricter parenting of daughtersevidence of raising daughtersmay be apparent even if parents experience equally warm relationships with children of both genders second more research is needed to explore the circumstances under which differential affection toward sons and daughters may occur for instance some research has shown that stressful family circumstances contribute to higher levels of parents differential treatment of offspring although adolescent gender was unrelated our analyses revealed a significant effect of parent gender on parental warmth consistent with findings on white families mothers reported warmer relationships with their adolescents than did fathers this pattern may emerge because women tend to be more emotionally expressive in close relationships than men because parents reports of parent adolescent warmth may be biased by their inclination to respond in socially desirable ways however future work should examine youths relationship perceptions our data also revealed that controlling for youth age parents reported warmer relationships with younger versus older siblings this pattern may reflect parents learning from their experiences with earlier born offspring to be more effective in their roles with laterborn offspring findings pertaining to parent adolescent time were consistent with the idea that adolescence is a period of intensified gender socialization particularly by mothers within family comparisons revealed mother father differences in gendered differential treatment of adolescentaged siblings when the older sibling was a boy mothers invested more time in the younger sibling and when the younger sibling was a girl mothers spent relatively less time with the older sibling on the other hand though fathers spent more time with younger siblings neither older nor younger sibling gender moderated this effect further research is needed to fully understand this pattern of findings it may be that during adolescence african american mothers but not fathers are focused on gendered socialization of their offspring and thus devote more time to daughters given past work indicating that african american parents of infants spent relatively equal amount of time with boys and girls an important area for longitudinal research is to explore patterns of change in african american mothers and fathers time with sons and daughters across development it is notable that in this sample mothers did not spend significantly more time with youth than fathers a pattern that may reflect the more flexible parenting roles that are often discussed as a major strength of african american families this study also contributes to the literature documenting links between parent adolescent relationship qualities and adjustment of african american youth in line with a family systems approach we relied on reports from both parents and youth findings revealed that mothers and fathers relationships with their sons and daughters functioned in unique ways for instance maternal warmth was linked to fewer depressive symptoms in youth in contrast mothers warmth was negatively related to sons but not daughtersrisky behavior in the case of fathers warmth and shared time were associated with lower levels of youth risky behavior this latter pattern is consistent with the idea that fathers socialization may be more important for offsprings experiences in the world beyond the family for instance fathers have been shown to spend a greater proportion of their time with adolescents engaged in leisure and recreational activities than mothers the negative link between fathers time and risky behavior may emerge because of fathers supervision guidance or companionship in youths activities outside the home in addition to its substantive contributions this studys methodological strengths advance understanding of african american family dynamics first by focusing on a largely workingand middleclass community sample this research moves beyond a deficit perspective wherein african american families may be implicitly pathologized further as much research on african american families has focused on single mothers or families experiencing economic hardship it has been hard to disentangle the impact of sociodemographic factors from normative family processes second by relying on data from four family members this research avoided a monoreporter bias indeed fathers involvement in this study is noteworthy given that african american men are rarely represented in social science research and past work has often relied on mothers reports of fathering additionally by including mothers and fathers in the same analyses we were able to illuminate the unique effects of each parent on their childrens adjustment third directly comparing mothers and fathers from the same families in their relationships with sons and daughters provided a deeper understanding of the roles of parent and child gender in african american family dynamics this study also has applied implications findings revealed that variability in parentadolescent relationship quality in twoparent families has implications for youth problem behaviors and suggests the importance of strengthening these family dynamics in an effort to support youths positive adjustment poor mental health outcomes have been identified as an area in which african american youth fare considerably worse than their counterparts from other racesethnicities considering the present findings maternal warmth may be particularly important for promoting mental health wellbeing among african american youth with regard to risky behavior our findings revealed that even among residential fathers and controlling for mother adolescent relationship quality the warmer fathers were with their adolescentaged children and the more time they spent with them the less likely sons and daughters were to participate in delinquent activities thus targeting both domains of relationship quality in interventions may help to reduce negative youth outcomes limitations and future directions in the face of its strengths several factors limited this studys conclusions first our sample including its small size the geographically circumscribed location from which it was gathered and the relatively high levels of income and education of participants limited the generalizability of our findings second the crosssectional design did not allow for conclusions about direction of effect parent child influences are bidirectional and youths adjustment may have implications for parentadolescent relationships as well as the other way around third though we measured two components of relationship quality there are many other aspects of parent adolescent relationships that may be linked to gender and have distinct implications for youth outcomes finally our relatively small sample size limited power to detect interactions between parent gender youth gender and youth birth order nonetheless this study provided important insights into family processes in the neglected population of twoparent workingand middleclass african american families the research design which allowed for withinfamily comparisons illuminated family gender dynamics that would not be evident in betweenfamily comparisons rather than supporting the contention that african american parents demonstrate gendered differential treatment toward sons and daughters our findings reflect the multidimensional nature of gender adolescent gender was not a factor in parental warmth but mothers reported warmer relationships than fathers and parents shared time differed as a function of their offsprings gender this work also contributed to a small body of literature showing the uniquely important contributions of african american fathers to their childrens adjustment beyond mother adolescent relationship quality higher paternal warmth and parent youth shared time were associated with lower levels of adolescent risky behavior given the relatively high rates of risky behavior among african american youth this finding underscores the importance of directing interventions toward african american fathers differences in parents time with older versus younger siblings as a function of parent gender and adolescent gender and birth order note bars represent parents time with younger siblings subtracted from parents time with older siblings such that higher scores reflect relatively more time with younger siblings

using multiinformant data from 134 twoparent african american families the goals of this study were to a describe parent adolescent warmth and shared time as a function of parent and youth gender and b assess links between these indices of relationship quality and adolescent adjustment mixedmodel ancovas revealed that mothers reported warmer relationships with adolescents than fathers and both parents reported warmer relationships with younger versus older offspring interparental differences in time spent with sons and daughters and older and younger siblings were also found tests of multilevel models indicated that greater maternal warmth was associated with fewer depressive symptoms and less risky behavior for sons and more paternal warmth and shared time with fathers were associated with less risky behavior in youth discussion highlights the utility of cultural ecological and family systems perspectives for understanding parentadolescent relationships and youth adjustment in african american familiesadolescence african american parenting maintaining strong family bonds during the renegotiation of parent child relationships in adolescence is paramount for youth adjustment steinberg 2001 parent adolescent relationships characterized by high warmth and involvement may protect youth from adjustment problems carltonford paikoff oakley brooksgunn 2008galambos barker almeida 2003 whereas most research on this topic is based on betweenfamily comparisons of youth family systems theory calls attention to withinfamily variability from a systems perspective families comprise interdependent individuals who make unique contributions to family dynamics and who have different experiences in and perceptions of their shared family context eg minuchin 1985 although a systems perspective holds that mothers and fathers will make unique contributions to their sons and daughters development empirical research on the roles of gender for parent adolescent relationships is sparse and we know little about the differential experiences of boys and girls who grow up in the same family galambos berenbaum mchale 2009

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introduction various studies have reported genetic factors for diabetes mellitus 1 2 3 4 warranting its familial aggregation 5 6 7 8 nevertheless few studies have investigated the clustering of diabetes 910 particularly in married couples who were not genetically related a crosssectional study on concordant diseases in couples revealed that the odds of diabetes concordance was significantly high after adjustment for age alone but not after adjustment for age smoking and body mass index 11 the findings regarding the spousal concordance of diabetes are substantially inconclusive moreover age is considered a crucial determinant of diabetes studies have reported that old age is strongly associated with a high risk of diabetes 48912 the risk increases with age thus middleaged and elderly couples are susceptible to diabetes because of slowing metabolism and obesity a common phenomenon across all the studies on the family clustering of metabolic disorders is the lack of nonfamily counterparts who did not share the same environments hence it is imperative to conduct a concordance study that compares the disparity in the risk of diabetes between couples and noncouples to ascertain the effects of a common environment while examining the age vulnerability most studies on family clustering have reported merely univariate statistics or investigated a very limited number of associated factors however familial clustering or concordance pertains to the common experiences of certain morbidities within a family and is conceivably involved with the risk factors in individual family members therefore examining the factors associated with diabetes in each spouse is crucial for obtaining a more comprehensive understanding of diabetes concordance in couples prior research has reported sex differences in the occurrence of diabetes men were more likely to be diagnosed as having hyperglycemia than are women particularly men with an older age and habits of smoking and drinking 91213 a study indicated no significant association between income level and diabetes prevalence 14 however most studies have reported an association between income and diabetes with low household income identified as the risk factor 1516 moreover the risk of diabetes and other metabolic syndromes varied with occupations because of varying workrelated physical activities 1316 although higher levels of urbanization were associated with higher risk of diabetes 15 the association remains inconsistent in addition studies have indicated that diabetes could be associated with certain chronic diseases such as hiv and psychiatric morbidities 17 18 19 the effects of the potential associated factors on the spousal concordance of diabetes require investigation scarce studies have examined a control group and associated factors for diabetes clustering in couples therefore the present study sought to determine the spousal concordance of diabetes by adopting a mathematically matched group of noncouples to compare the risk of diabetes concordance between couples and noncouples by using nationally representative data methods hypothesis and research design this study hypothesized that the risk of spousal concordance of diabetes is associated with the individual and shared characteristics of spouses the individual characteristics of spouses may exert different effects on spousal concordance of diabetes moreover the study hypothesized the existence of a disparity in the risk of concordance between couples and noncouples the two hypotheses were tested in a longitudinal populationbased cohort by using a casecontrol design the study was approved by the research ethics committee of china medical university hospital taiwan data source and study sample the national health insurance program established in 1995 provides comprehensive health care benefits to more than 997 of the residents of taiwan all the medical claims from this universal program are managed by the national health research institutes which releases the populationbased national health insurance research database this retrospective study retrieved longitudinal data from the 20022013 registry of the nhird which contains the reimbursement claims of 1 million randomly sampled beneficiaries the nhri has indicated that this nhird subset can completely represent all the enrollees the claim diagnoses in the nhird were coded using the international classification of diseases ninth revision clinical modification this study used the data fields relation and encrypted individual identifiers to match married spouses from the nhird registry only two individuals having a relationship status of being insured and dependent spouses were identified as a couple by using spouse in the data field relation and the prerequisite of the encrypted identifiers mutually matched between the two spouses furthermore to obtain an initial diagnosis of diabetes throughout the observation period individuals diagnosed as having diabetes mellitus in 2002 were excluded from the study patients younger than 16 years were also excluded initially data of 5680 couples were obtained however 43 patients were excluded because of inadequate or missing data consequently the current study identified a cohort of 5643 married couples comprising 11286 individuals to ascertain the similarity between the case and control groups except for the couple status the case group was matched with the control group in terms of the same single value of sex age and comorbidities through 11 propensity score matching to reduce selection bias 20 this procedure was repeated twice for each member of a couple to obtain two randomly selected noncouple counterparts thus the three matched variables were tested twice for any significant differences between the two groups the results indicated high similarity with no differences in sex age or comorbidities thus confirming that the couples and noncouples qualified for the comparison psm provides an alternative to adjust for covariates at the level of multivariate analysis 21 consequently 5643 couples and 5643 noncouples were included in the subsequent analysis variables the concordance of diabetes was determined using a dichotomous outcome variable concordance was reported if both spouses or counterparts were diagnosed using icd9cm codes for diabetes mellitus otherwise discordance was reported the present study included two categories of independent variables that are possibly associated with diabetes 1 characteristics of the insured spouse comprising sex age premiumbased monthly salary occupation urbanization level region catastrophic illness or injury and comorbidities and 2 characteristics of the dependent spouse comprising age catastrophic illness or injury and comorbidities the urbanization level and region were considered common environmental characteristics of the couples the remaining variable was the characteristics of the individual spouses legally the taiwan government allows only heterosexual marriage thus one sex that of the insured spouse was used to eliminate collinearity age did not pass the normality test including skewness and kurtosis and was therefore classified into five ordinal levels according to the frequency distribution furthermore premiumbased monthly salary occupation region and catastrophic illness or injury were defined on the basis of the official nhi classifications the national health insurance administration issues the catastrophic illness and injury card to patients with severe illness or injury patients with numerous catastrophic illness and injury conditions such as regular dialysis or permanent disability can apply for the card after the severity reaches the official criteria of the nhi program and is verified by a boardcertified physician comorbidities were assessed using the charlson comorbidity index 22 a frequently used measure in clinical research after original scoring from 0 to 6 conducted by weighting icd9cm codes for each spouse this study classified comorbidities into 0 and 13 because of the lowfrequency distribution of cci scores exceeding 3 the urbanization level was graded using a 5point scale with 1 and 5 indicating the highest and lowest urbanization levels respectively all the 11 independent variables were measured on a categorical or an ordinal level all the variables in the casecontrol design were defined at the pair level data analysis in this study data were analyzed through statistical analysis and data mining statistical methods included the chisquared test and logistic regression the chisquared test determined the prevalence rates of diabetes concordance at the bivariate level logistic regression was used mainly for predicting diabetes concordance at the multivariate level with the adjusted odds ratio and corresponding 95 confidence interval because the members of the couples and noncouples were matched for the three variables conditional logistic regression was used to analyze the matched pair data without the matching factors in the regression model 2324 the conditional likelihood was estimated within the same matched set for binary diabetes concordance 25 moreover collinearity diagnostics were computed using indices including variance inflation and tolerance for data mining c rt and apriori two methods under the no hypothesis paradigm were used to explore hidden patterns that statistics might fail to detect 2627 the application of data mining techniques in longitudinal study analysis of a large clinical data source may discover useful information on disease prediction and health care delivery 28 29 30 c rt a decision tree was used for classification 31 the apriori algorithm of association rules was used to mine for potential associations in the extracted research data 32 data mining largely served as a supplement to statistics in contrast to theorybased statistical analysis data mining is substantially more datadriven research that analyzes the individual level factors associated with the couple concordance of diabetes is still lacking therefore this study used statistics and data mining for the optimization of pioneering modeling for the concordance factors the joint findings engendered by the two approaches should increase the strength of evidence on diabetes concordance data were analyzed using sas 94 and ibm spss modeler 13 results the common characteristics of 11286 individual spouses were analyzed and merged in the unit of a couple catastrophic illness or injury and cci 2 were significantly associated with a higher prevalence of spousal concordance insured spouses who were soldiers social security insured veterans and associated with religious groups were more likely to develop spousal concordance of diabetes compared with those involved in other occupations this study did not detect any signs of collinearity table 4 presents the logistic regression results the results of the unadjusted model indicated that 10 independent variables were significantly associated with spousal concordance after all other covariates were held constant nine variables remained significantly associated with spousal concordance of diabetes male insured spouses were more likely to experience spousal concordance than their female counterparts were insured spouses aged 4554 5564 and 65 years were more likely to experience spousal concordance compared with those aged 1644 years moreover insured spouses residing in areas with urbanization levels of 2 and 3 were more likely to experience spousal concordance compared with those in level 1 urbanization areas the odds of spousal concordance were significantly lower in insured spouses residing in the northern region than those residing in taipei regarding health characteristics the odds of spousal concordance were significantly higher in insured spouses with catastrophic illness or injury than in those without these factors the odds of spousal concordance were significantly higher in insured spouses with mediumhigh comorbidity than in those without comorbidities dependent spouses aged 4554 5564 and 65 years were more likely to experience spousal concordance compared with those aged 1644 years moreover dependent spouses with catastrophic illness or injury were more likely to experience spousal concordance compared with those without these factors in addition dependent spouses with mediumhigh comorbidity were more likely to experience spousal concordance compared with those without comorbidities table 5 presents the results of couplelevel analysis following 11 dual psm the chisquared test revealed a significant association of marital status with diabetes concordance couples were significantly associated with a higher prevalence of concordance than were noncouples the percentage of one spouse diagnosed with diabetes in couples was higher than that of one individual with diabetes in noncouples this phenomenon is consistent among both male and female moreover conditional logistic regression indicated that marital status was significantly associated with diabetes concordance the odds of diabetes concordance were significantly higher in couples than in noncouples after feature selection data mining was performed with a reduced set of relevant data the following classification rules were identified for predicting spousal concordance 1 cci 1 fourth fifth and sixth categories of occupation and residence in northern and southern regions for insured spouses and 2 age 55 years and cci 1 for dependent spouses for predicting no spousal concordance the classification rules were a monthly income of us 960 and no comorbidities for insured spouses and age 1654 years and no comorbidities for dependent spouses the prediction accuracy of c rt was 857 909 the apriori algorithm was not sensitive in detecting the association rules for the presence of spousal concordance however the acquired rules for predicting no spousal concordance included the male sex age 1644 years no catastrophic illness or injury and no comorbidities for insured spouses as well as age 1644 years and no catastrophic illness or injury for dependent spouses confidence in apriori is an indication of the probability that the rule is correct in this study the confidence of the apriori algorithm was 953 982 indicating a strong association between the extracted patterns and spousal concordance of diabetes overall the indices of accuracy and confidence demonstrate effective data mining 3334 discussion high concordance in couples versus low concordance in noncouples to our knowledge this study is the first that investigated spousal concordance of diabetes in a matched casecontrol design a contrast of high and low concordance rates of diabetes in couples and noncouples respectively was identified the dual psm analysis revealed this phenomenon in both prevalence rates and ors the determined prevalence rate of spousal concordance was 519 in couples strongly higher than in noncouples the or of 61743 represents the marked effect of a common family environment on the development of diabetes in couples and deserves emphasis both couples and noncouples were matched by sex age and comorbidities therefore the high contrast in the concordance is not attributable to oldage vulnerability and is closely related only to the coupled status assortative mating and similarities between both members of a married couple in a common environment may explain the high concordance of diabetes in couples 35 studies have indicated resemblances between spouses 3637 particularly in longstanding couples notably collectivism in taiwanese culture 38 may reinforce behavioral resemblances in couples furthermore through cohabitation in the same family environment concordant health behaviors including exercise and dietary habits and shared lifestyles in couples can be shaped 39 40 41 42 and might thus lead to a shared exposure such as concordant obesity 43 to diabetes 44 hence familybased intervention for modifiable health behaviors is a priority in clinical practice individuallevel characteristics predicting couplelevel concordances statistical analysis and data mining yielded the combined results regarding factors associated with spousal concordance of diabetes in addition to the couple status nine factors including personal and shared characteristics of spousal concordance warrant attention most insured spouses were men who could have a higher risk of diabetes than their female counterparts 923 the prevalence rate of diabetes was higher in insured spouses thus explicating the finding that insured men were more likely to experience spousal concordance of diabetes than were insured women old age was markedly associated with high risks of concordant diabetes particularly in spouses aged 65 years this observation is in accordance with the findings of previous studies 4546 the urbanization level and region which are the shared geographical characteristics of couples were identified as the determinants of spousal concordance levels 2 and 3 of urbanization were associated with higher odds of spousal concordance whereas residence in the northern region was associated with a lower risk the geographical disparities in concordant diabetes warrant further research and require the attention of health policymakers the findings regarding comorbidities are similar to those previously reported 4748 and indicate that medical conditions of individual spouses contribute to concordant diabetes in couples overall diabetes in a spouse may indicate the risk of diabetes in the partner a previous study indicated that spousal diabetes is associated with a 26 increase in the risk of diabetes in the partner 49 echoing the present findings the phenomenon of spousal concordance of diabetes is evident therefore the clinical prevention of diabetes should target spouses whose married partners were diagnosed as having diabetes by applying the individuallevel and shared geographical risk factors identified in this study including old age midrange urbanization and chronic morbidities coupleoriented health insurance couplitation health insurance schemes might adjust medical payments by sex age and morbidities such as capitation reimbursement 50 a family history of certain chronic and catastrophic illnesses among genetically related family members is considered for determining premiums nevertheless the spouse history of diabetes is typically not involved in the risk rating of individuallevel health insurance plans therefore the present study proposes a novel yet reasonable direction of a coupleoriented insurance scheme couplitation that is aimed at developing comprehensive coverage and reimbursements for spousevulnerable chronic diseases 51 52 53 particularly diabetes couplitation may improve early detection through examination in a manner paralleling capitation this spouserelated risk rating of an insurance scheme requires feasibility analysis in future studies the limitations of the present study are mainly related to the database used first the nhird does not include information on the educational level health behaviors laboratory test results cohabitation duration and other joint characteristics of the couples the absence of these data weakens the statistical strength of this study second the body mass index is a major risk factor for diabetes the absence of this factor may result in residual confounding and thus bias the findings in an unknown direction third high level of awareness or knowledge of symptoms of diabetes may lead to early diagnosis due to the lack of awarenessrelated data in the nhird the current study failed to take this factor into consideration finally all spouses retrieved from the database were limited to the insureddependent relationship the generalization of the study findings to all other relationships requires deliberation conclusions this study involved cohort and casecontrol designs individualand couplelevel analyses and statistical analysis and data mining all of which were aimed at providing strong evidence this study adds to the existing knowledge base by determining the evident effects of a common family environment and individual characteristics on diabetes concordance in couples oldage vulnerability in diabetes cannot explain this high concordance phenomenon in couples diabetes in one spouse indicates the risk of diabetes in the partner therefore this study suggests that familybased diabetes health care and clinical intervention be conducted using the individual risk factors identified in this study future studies may focus on investigating the spousal concordance of a specific type of diabetes all relevant data are within the paper data curation jongyi wang yatun yang formal analysis yatun yang funding acquisition jongyi wang methodology jongyi wang project administration jongyi wang resources jongyi wang software yatun yang validation chiushong liu chihsuan lung writing original draft jongyi wang writing review editing chiushong liu chihsuan lung minghung lin

spousal clustering of diabetes merits attention whether oldage vulnerability or a shared family environment determines the concordance of diabetes is also uncertain this study investigated the spousal concordance of diabetes and compared the risk of diabetes concordance between couples and noncouples by using nationally representative dataa total of 22572 individuals identified from the 20022013 national health insurance research database of taiwan constituted 5643 couples and 5643 noncouples through 11 dual propensity score matching psm factors associated with concordance in both spouses with diabetes were analyzed at the individual level the risk of diabetes concordance between couples and noncouples was compared at the couple level logistic regression was the main statistical method statistical data were analyzed using sas 94 c rt and apriori of data mining conducted in ibm spss modeler 13 served as a supplement to statisticshigh odds of the spousal concordance of diabetes were associated with old age middle levels of urbanization and high comorbidities all p 005 the dual psm analysis revealed that the risk of diabetes concordance was significantly higher in couples 519 than in noncouples 009 or 61743 p 00001 a high concordance rate of diabetes in couples may indicate the influences of assortative mating and shared environment diabetes in a spouse implicates its risk in the partner familybased diabetes care that emphasizes the screening of couples at risk of diabetes by using the identified risk factors is suggested in prospective clinical practice interventions

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introduction gender dysphoria is characterized by clinically significant distress or impairment in important areas of functioning that can arise in many transgender people as a consequence of the incongruence between the experienced gender and the one assigned at birth 1 in portugal being transgender is legal and protected under antidiscrimination laws 2 transgender individuals have the right to change their name and gender on legal documents and genderaffirming healthcare is available through the public health system 2 in the last years there has been an increasing acceptance of gender diversity and transgender rights and portugals gender identity law of 2011 is a significant aspect of this change allowing individuals to change their gender marker on identification documents without the need for medical procedures 23 however despite the legal protections in place there is still discrimination and stigmatization of transgender people in society particularly in relation to employment education and access to healthcare 2 although more public hospitals are offering genderaffirming treatments there are still long waiting lists for these services indicating the need for further improvements 4 the prevalence of transgender individuals in portugal is unknown but national data shows that between 2011 and 2021 1227 transgender portuguese changed their gender marker in the civil registration system 3 gd treatment consists of social transition psychotherapy hormone therapy and surgery 5 studies have shown that these therapies are effective in treating gd and can lead to improvements in mental health issues 6 while the treatment plan is personalized hormone therapy is often the initial medical intervention and is based on individual objectives riskbenefit analysis the presence of comorbidities and socioeconomic factors 5 masculinizing therapy is typically achieved through testosterone while feminizing hormone therapy involves a combination of estrogen and an androgen blocker which is usually more complex 5 the timing of appearance of the desired physical changes is highly variable some features might take as little as one month to be noticeable while others can take up to six or more months and even years to reach their peak 7 the main expected effects of masculinizing therapy are amenorrhea clitoris enlargement and voice deepening while feminizing therapy most markedly induces breast development softerless oily skin and a decrease in semen production spontaneous erections and testicle size 7 also masculinizing therapy is expected to increase body and facial hair decrease body fat mass and increase lean mass on the other hand feminizing hormone therapy is expected to have the opposite effects 7 genderaffirming hormone therapy is not exempt from side effects and may be associated with erythrocytosis weight gain acne alopecia and sleep apnea in masculinizing therapy 57 in feminizing hormone therapy side effects include venous thromboembolism gallstones hepatic toxicity weight gain dyslipidemia and cardiovascular disease 57 the first aim of our study was to evaluate how significant the perception of the desired physical changes was and the consequent satisfaction with such changes after at least one year of uninterrupted gaht in transgender individuals our second aim was to explore the impact of gaht on trans peoples lives regarding sociopsychological variables such as selfesteem body image satisfaction psychological wellbeing and social and familial relations by rating them with a preand posttherapy score the third and last objective was to rate participants overall satisfaction with both therapy results and medical followup during treatment with this study we hope to get better enlightenment on gahts benefits and risks so that physicians can provide more evidencebased care to transgender patients it is also our desire to encourage other investigators to conduct studies in this underresearched area the participants of this study were adult transgender individuals residing in portugal currently undergoing or had undergone gaht regardless of the timeframe in which the treatment was conducted data was collected through an original nonvalidated questionnaire that was sent to the participants via email the authors developed the questionnaire in collaboration with portuguese psychologists specializing in the healthcare of transgender individuals the questionnaire was based on questions from several validated questionnaires freely available online such as the gender identitygender dysphoria questionnaire for adolescents and adults the trans woman voice questionnaire and the body image scale to identify potential participants for the study we collaborated with 12 portuguese lgbtqi associations and organizations these groups helped us by accessing their databases and sending an invitation to all their registered transgender associates inviting them to participate in the study the invitation contained the questionnaire google forms link and all transgender associates who did gaht were invited to participate we obtained a total of 147 responses of which 142 were valid two were excluded because they were duplicated and three were excluded because the answers werent congruent throughout the questionnaire having the aim of this article in mind only the answers of participants who took gaht for at least one uninterrupted year were included resulting in a total of 114 relevant answers to the questionnaire of which 87 were from individuals on masculinizing therapy and 27 from people undergoing feminizing treatment all data was registered anonymously respecting participants data protection this study was approved by the local ethics committee informed consent was explained at the beginning of the questionnaire and participants had to give consent to proceed with the questionnaire measures the studys questionnaire was created by the authors using the google forms platform consisting of 60 different questions 19 of each addressing demographics gaht physical and sociopsychological effects impact and consequent satisfaction with both results and medical followup other questions aimed to evaluate how the treatment was being oriented participants knowledge about the transition process therapy regimen safety adhesion and compliance for this articles aim only the answers to the first 19 questions are presented and discussed to answer some of the items on the questionnaire an ordinal likertstyle scale ranging from 0 to 6 was used for the first aim regarding gaht effects participants rated their perception of physical changes development from 0 no changes to 6 very significant changes and their satisfaction with them from 0 not satisfied to 6 totally satisfied participants also indicated the physical and psychological adverse effects that they experienced by choosing them from a list presenting the most common side effects explained with common nonmedical language while also having the option of writing down any other one not listed to achieve the second goal respondents evaluated gahts sociopsychological impact rating the following variables before and after at least one year of gaht in a retrospective manner selfesteem body image satisfaction psychological wellbeing social relations and family relations the third goal was accomplished by rating the general satisfaction with gahts results and with the medical followup received during the treatment with a scale ranging from 0 not satisfied to 6 totally satisfied statistical analysis categorical variables were presented as frequency distribution and compared using pearsons chisquared test for each continuous variable normality was tested by histogram observation and the kolmogorovsmirnov test and since the almost totality of continuous variables had a nonnormal distribution results were presented as medians samples were compared using nonparametric tests such as wilcoxon signedrank test for paired variables and the mannwhitney u test for independent variables with a significance level set at 005 data analysis was performed using the spss statistics v 27 software demographics respondents age ranged from 18 to 62 years and their median age was 240 years participants median age of recognition of selfgender identity was 80 and initiation of public expression of their experienced gender was 180 years of age participants initiated hormonal therapy at a median age of 210 figure 1 presents this data organized in stacked bar charts figure 1 participant demographics results are presented as absolute frequencies a gender identity b gender expression abbreviations gaht genderaffirming hormone therapy most participants had treatment for two to five years followed by one to two years and five years or more table 1 in group m the changes evaluated with the best median score concerning the participants perception of their appearance were amenorrhea and clitoris enlargement the changes classified as most satisfactory were amenorrhea and clitoris enlargement followed by voice deepening perception of changes as for group f regarding the perception of physical alterations those evaluated with the best median score were the decrease in semen production spontaneous erections and testicle size and softerless oily skin the physical changes rated as the most satisfactory were also the decrease in both spontaneous erections and semen production regarding side effects 897 of the participants from group m experienced some adverse effect from gaht whilst 963 of the respondents from group f reported at least one side effect as shown the most frequently stated side effects from participants in masculinizing therapy were mood swings acne and alopecia while respondents who underwent feminizing therapy mostly reported decreased libido and mood swings sociopsychological impact table 4 shows the sociopsychological impact of gahts effects variable table 4 sociopsychological impact of gahts physical changes results are presented as median of the score attributed by the participants to each variable preand posttherapy abbreviations gaht genderaffirming hormone therapy participants retrospectively rated their selfesteem before and after gaht with a median of 15 and 50 points respectively of note although the medians of the scores corresponding to pretreatment selfesteem differed between groups m and f this difference was not statistically significant median scores attributed to body image satisfaction were 10 points before and 50 points after therapy once again while the medians of scores relative to posttherapy body image satisfaction attributed to each group were different this difference was not statistically significant respondents rated their psychological wellbeing with a median of 30 points before and 50 points after gaht even though the medians of the scores attributed to posttreatment psychological wellbeing differed between groups m and f this difference was not statistically significant participants also rated their social relations before and after therapy with 30 and 50 points respectively lastly their family relations were evaluated with a median of 30 points pretreatment and 40 points posttreatment nonetheless the difference between the posttreatment medians of scores of both groups was not statistically significant all analyzed variables had a statistically significant improvement with gaht both in the total sample and in group m in group f all variables improved significantly except for psychological wellbeing satisfaction these participants rated their overall satisfaction with treatment results with a median of 50 points and their satisfaction with received medical followup with a median of 45 points the difference between the medians of the scores attributed to the received medical followup by groups m and f was not statistically significant discussion the 2015 us transgender survey conducted by the national center for transgender equality revealed that among transgender individuals using gaht 39 reported using testosterone while 64 reported using estrogen andor progesterone evidencing a much greater number of people seeking feminizing treatments 8 in contrast our study demonstrated an inverse relationship with a larger proportion of individuals seeking masculinizing hormone treatments this correlation was likewise observed in two additional studies conducted on the transgender population in portugal suggesting that this might be characteristic of the portuguese context 49 while there is no current explanation for this we suggest that cultural and societal factors as well as differences in healthcare access and availability of hormone therapy options may contribute to the observed disparities sample size recruitment methods and study design are important considerations that may also influence these findings further research is needed to better understand the underlying factors that may explain these differences our study results were consistent with other international studies that have shown the significant physical changes induced by gaht 10 11 12 13 14 15 16 17 18 our study reinforces the findings of others that side effects are mostly mild with acne and libido loss being among the most frequent in transgender individuals receiving masculinizing or feminizing hormone therapy respectively and that severe adverse alterations such as erythrocytosis venous thromboembolism or even important hepatic toxicity seem to be rare 16 17 18 19 previous research has demonstrated the positive impact of gaht on body image and selfesteem in transgender individuals with findings similar to ours gaht can improve genderbody conformation meaning that transgender individuals who undergo gaht tend to experience a greater sense of alignment between their gender identity and their physical appearance 13 20 21 22 23 this in turn can reduce body image dissatisfaction and increase satisfaction with appearance as well as overall selfesteem 13 20 21 22 23 these positive effects on body image and selfesteem can have significant implications for mental health as body dissatisfaction and low selfesteem are risk factors for depression and anxiety 13 20 21 22 23 the results here presented similarly to the ones of other studies also demonstrated improvements in psychological wellbeing and reduced risk of suicidal ideation following gaht a probable explanation for this is that making the body characteristics more congruent with the experienced gender reduces dysphoria and even potentially decreases marginalization allowing better results in mental health which considerably diminishes the risk of suicide attempt 24 25 26 psychological wellbeing did not improve in a statistically significant way in group f possibly because of the greater social stigma that trans women face in comparison to trans men even after transition a study from verbeek et al showed that trans women deal with higher social stigma not only because of misogyny itself but also for being perceived as a threat to cisgender women 27 our study also revealed an improvement in social and family relations after hormone therapy as suggested by other researchers although individual experiences may vary since not all transgender individuals have supportive families and peers and some may experience rejection or hostility several studies have found that genderaffirming treatment can result in positive changes in relationships 20212829 a study by gorinlazard et al found that transgender individuals who underwent hormone therapy reported improvements in their family relationships including increased acceptance and support from family members 20 this may occur because genderaffirming treatments seem effective in reducing gender dysphoria and improving overall wellbeing in transgender people which can have positive effects on relationships with family members and other social connections 20212829 other studies have also reported significant improvements in the quality of life of transgender individuals who undergo gaht our study similarly found that individuals who received gaht reported a high level of satisfaction with the results which suggests that hormone therapy can have a positive impact on the overall wellbeing of transgender individuals the aforementioned improvements in various areas of transgender individuals lives may collectively contribute to the substantial enhancements in their reported quality of life 2030 all these findings are in line with the growing body of evidence that supports the use of gaht as a crucial component of genderaffirming care strengths and limitations the current study has several notable strengths that contribute to the field of research firstly the study achieved a high participant count relative to the expected size of the target population indicating a strong level of engagement and interest from individuals within the studied population secondly the study was able to acquire data regarding variables that had not been previously explored in related investigations providing new insights into the topic under investigation additionally the study represents one of the few investigations of its kind conducted in portugal emphasizing the significance of its contribution to the field together these strengths highlight the value of the current study and provide an additional foundation for future research in this area nonetheless several potential limitations should be taken into account when interpreting the results firstly differences between the number and characteristics of the participants from each group as well as a small sample size for some variables participant selection procedures and limited data comparison and analysis may have influenced the studys findings in addition the individualized nature of gaht regimens different treatment duration for each participant the uncertainty of medication adherence and the inclusion of participants from various countries with potential interpopulational and biological differences should also be acknowledged furthermore the cohort mainly consisting of participants from portugal limits the generalization of the results moreover due to the retrospective nature of the study and the lack of a validated questionnaire participants evaluation of pretreatment variables may have been less accurate finally the potential for bias in participants responses due to the sunk cost fallacy along with other factors such as concurrent treatment or personal life events that may have influenced the results were not controlled for in the study as a result caution should be exercised when generalizing the findings to other populations or settings gender dysphoria is a recently acknowledged issue and it has only recently gained recognition in the field of medicine there is still a dearth of largescale prospective studies that are necessary to optimize its management and to provide individuals who identify as transgender with the best possible treatment options to address this gap in knowledge it is critical to undertake research that employs more standardized methods of data collection and that follows clearly delineated treatment protocols conclusions this study provides further evidence that gaht is effective and several expected satisfactory changes can be observed after at least one uninterrupted year of hormonal therapy the adverse effects reported were also mostly nonsevere and nonlifethreatening for transgender people who seek transition gaht is consistently associated with improvements in selfesteem body image satisfaction psychological wellbeing and social and family relations our study also revealed that there is general satisfaction with both therapy results and medical followup this study brings new evidence to physicians that gaht seems to be important to increase the physical psychological and social health of transgender people seeking medical transition probably associated with the improvement in the quality of life verified in other studies additional information disclosures

gender dysphoria treatment includes genderaffirming hormone therapy gaht studies are still lacking on how to characterize its effects and impact on transgender peoples lives more effectivelyto study the physical and psychological effects of gaht on transgender individuals assess its impact on their lives and rate their overall satisfactionparticipants n 114 ages 1862 years median age 240 210 330 years included transgender adults residing in portugal who were undergoing or had undergone hormonal therapy for at least one uninterrupted year participants completed an original questionnaire for most items an ordinal likertstyle scale ranging from 0 worst result to 6 best result was used descriptive statistics and nonparametric tests including pearsons chisquared test wilcoxon signedrank test and mannwhitney u test were used to analyze categorical and continuous variables with a significance level set at 005the outcomes included desired physical changes rating perception and satisfaction with changes side effects of gaht the sociopsychological impact of gaht on selfesteem body image psychological wellbeing social and family relations overall satisfaction with treatment results and medical followup the changes classified as the most perceptible in those undergoing masculinizing treatment group m were amenorrhea 6 5060 points and clitoris enlargement 6 5060 points these were also the ones rated as the most satisfactory 6 6060 points for amenorrhea and 6 4060 points for clitoris enlargement on those undergoing feminizing therapy group f the alteration voted as the most perceptible was sperm production decrease 6 2060 points and the ones classified as the most satisfactory were sperm production decrease 6 4060 points and spontaneous erections decrease 6 5060 points side effects were reported by 897 of group m mood swings were the most common and 963 of group f decreased libido was the most frequent the sociopsychological impact of hormonal treatment was significantly positive in all analyzed variables p 0001 overall satisfaction with treatment results and medical followup were rated with 5 points and 45 points respectivelythis study provides clinicians with more evidence that gaht may improve the physical psychological and social health of transgender people seeking medical transitionthe strengths of the current study include a high participant count relative to the target population the acquisition of data on previously unexplored variables and the significance of being one of the few investigations of its kind conducted in portugal however the study has limitations including differences in participant characteristics a small sample size for some variables potential bias due to the retrospective nature of the study individualized treatment regimens and the inclusion of participants from different countries which limit the generalization of the results1 2 1

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background public health in the americas has experienced significant improvements over the last few decades however considerable challenges persist in the prevention and control of diseases suboptimal levels of maternal and child health insufficient human and infrastructure resources and wide geographical and cultural differences add further complexity to the situation in the region 1 there are 23 leading causes of death in countries of the americas some of which are preventable three examples illustrate the preventable nature of major causes of death diabetes can be largely prevented by a healthy diet and lifestyle hivaids can be prevented by taking adequate precautions during sex and finally interpersonal violence is a scourge that must be confronted by the integration of actions in many sectors of society 2 in all of these cases and in many others access to reliable and quality health information and appropriate medical advice can contribute to a dramatic reduction in the mortality figures of these countries from the declaration of almaata 3 to the millennium declaration 4 access to reliable health information and knowledge sharing through use of information and communication technologies has been considered essential for health development 5 in a setting where a large amount of content is available about different health topics some of which is produced by institutions with conflicting interests and which can be consumed through different channels governments must be the preferred source of information for citizens to consult for health information one of the key tools governments have available to provide access to information is their presence on the internet particularly through their social media profiles in order to address these realities we conducted a study to analyze the presence of national health authorities on social media in 18 spanishspeaking latin american and caribbean countries and the availability of information on the leading causes of death on the social media profiles of national health authorities this study refers to the actions that national health authorities can take on the internet to share and make available information of interest on their 10 leading causes of death the information gathered intends to motivate national health authorities to reach out to their populations with internet access by increasing their activity on social networks methods the research methods selected to undertake this research were the following a literature review for the development of the conceptual framework data collection by structured and direct observation about social media presence of national health authorities and a search for information about the leading causes of death on their online institutional profiles a comparative analysis by country was conducted on the collected data target population the americas is the region with the secondhighest internet access rates 66 compared to 776 in europe 6 in latin america specifically in the 18 countries part of this study a total of 188 million people are connected to the internet the percentages of penetration vary significantly when considering that for instance in chile internet penetration reaches 72 compared to nicaragua where the proportion of the population with internet access is 17 considering total connectivity data the median penetration in the analyzed countries is 446 regarding social media penetration in 2013 784 of internet users in latin america participated in social networksa percentage significantly higher than that of north america and western europe even though the latter two had higher internet penetrations than latin america 7 additionally latin american users spend the most time using social media with an average of 86 hmonth per visitor regarding audience profile no gender differences were found in any region with 50 women and men visiting social media sites the main audience consists of people 1534 years of age with regards to the most visited social media sites facebook is the market leader with 956 of time consumed on social media 8 the national health authorities in 18 spanishspeaking countries in latin american and the caribbean are the focus of this study these countries are argentina bolivia chile colombia costa rica cuba dominican republic ecuador el salvador guatemala honduras mexico nicaragua panama paraguay peru uruguay and venezuela the variables surveyed were the presence of these institutions in social media sixteen profiles on twitter 15 profiles on facebook and 12 profiles on youtube were analyzed for a period of 6 months within the framework of this work national health authorities means those institutions that by constitutional mandate are the public health governing bodies of a country namely health ministries and secretariats at the national level selection of terminology official who country health profiles 9 were consulted to find the 10 main causes of death which served as reference for the selection of terminology figure 3 shows a sample country health profile issued by who it is worth mentioning that this information was last updated by who in 2012 synonyms were also used to broaden the possibilities of retrieving information in the platforms searched the decs controlled vocabulary 10 was used to facilitate the search for synonyms in addition google trends was used to detect other synonyms for the terms used to trace information on top causes of death 11 it was clear from the search that there were no synonyms different enough to affect the total number of results retrieved the list of keywords and synonyms used on leading causes of death is included in additional file 1 according to the analysis of the 18 countries under study 23 leading causes of death affecting these countries were identified since the official information on leading causes of death was originally provided in english the pan american health organization website 12 was used for translation into spanish and to ensure the consistency of spanish terminology used in latin american countries exploratory and descriptive analysis for the exploratory and descriptive analysis of the presence of national health authorities on social networks facebook twitter and youtube were used as key sources of information only institutional profiles that were accessible from health authorities official websites were used as sources the presence of national health authorities on google instagram and flickr was negligible so an examination of these platforms was not undertaken in order to capture data and analyze the presence of national health authorities on social media the fanpagekarma tool was used 13 fanpagekarma makes searching content easierby downloading data in excel format for facebook and by a direct search on the platform for twitter using the selected terminology this tool made it possible to obtain a large number of analysis indicators for the three platforms surveyed on facebook the following indicators were analyzed among others number of followers mean posts per day shares per post comments per post and likes per post on twitter the analyzed indicators were number of tweets tweets per day favorites and retweets the analyzed indicators of youtube were total number of videos and total number of views comparative analysis after mapping the institutional presence on social media an analysis was conducted on whether national health authorities include information on the leading causes of death on their social media profiles mainly facebook and twitter a correlation indicated by pearsons correlation coefficient r measures the strength and the direction of a linear relationship between two variables the public health expenditure and the number of leading causes of death found on facebook and twitter according to the world bank public health expenditure consists of recurrent and capital spending from government budgets external borrowings and grants and social health insurance funds 14 limitations the study and the analysis were conducted in spanish the purpose of this restriction was to ensure the consistency of results and facilitate the comparison of results obtained in the countries involved special mention should be made of the exclusion of brazil a portuguesespeaking country and the largest latin american country it was excluded only because of the language criteria that ensured the consistency of the terminology used nevertheless the recommendations included in this study can guide any country willing to work on strategies to provide access to healthrelated information additionally the target audience to whom specific health interventions are directed through the use of social networks is exclusive to persons with internet access it should be remembered that internet access is still limited in the countries surveyed and that internet access is more readily available to the more affluent who frequently also have better access to healthcare therefore other actions on health promotion not related to social networks are beyond the scope of this study literature review at least six countries in latin america have conducted studies on the use of social networks in the context of health the recurrent topics in these studies are hivaids and tobacco regarding hiv the use of social networks was found useful in encouraging discussions around hiv testing and in addressing aidsrelated stigma 1516 with regard to tobacco the studies reveal that proposed legislation to ban tobacco advertising needs to include internet sites and related social media 17 moreover an institution in mexico conducted a study that demonstrated the apparent interest of the nonprofessional population to follow social network initiatives about health communications and the diffusion of material on the fight against tobacco use nevertheless more research is necessary in order to recognize the real impact of changing behavior 18 other prior studies on the use of social media by health authorities examined patterns and characteristics of social media adoption in state health departments in fig 4 fanpagekarma interface the united states in 2012 the presence of health departments on social media increased from 28 in 2008 to 41 in february 2012 the trends analyzed showed that the adoption of social media by state departments of health was associated with residential areas where internet penetration levels were higher it was determined that the presence on social media was positively associated with the development and dissemination of communication strategies on public health 19 another study found that the presence on social media recalls the trend towards unidirectional communication when the web came about when the core idea was to have a presence beyond the logic of why being present and of how to manage all the matters related to an institutional image 20 one additional study showed how health institutions used facebook twitter and youtube mostly to disseminate information about the organization followed by information about health education 21 in another study it was concluded that health authorities should adopt and apply this type of technology to assess protect and promote public health 22 results presence of national health authorities on social media the analysis of the presences of national health authorities showed that these institutions have presences on six different social media namely facebook twitter youtube flickr google and instagram sixteen of the 18 countries studied have an institutional presence on at least one of the six social media mentioned specifically almost 90 of the sample countries have an institutional presence on twitter and facebook with 16 and 15 out of 18 respectively youtube with 611 is the third platform with a significant institutional presence of national health authorities proportions are lower on other platforms flickr with 222 google with 166 and instagram with 55 the information about the presence of national health authorities on social media is included in additional file 2 national health authorities have presences on an average of almost three social media platforms only cuba and nicaragua have no institutional presence on any of the social media mentioned keeping in mind that the social media with the largest institutional presences are facebook twitter and youtube these three platforms were used as sources for the analysis of activity and information retrieval all the information relevant to the analysis of these three platforms is available in the additional file 3 facebook fifteen out of the 18 countries under study have institutional presences through their national health authorities on facebook costa rica panama and peru are the countries with the highest proportion of internet users who follow national health authority profiles on facebook uruguay honduras and colombia are the countries with the fewest followers in relation to the population with internet access representing 008 002 and 007 of the total population of those countries respectively the information about the population with internet access by country following national health authorities on facebook is included in additional file 4 the mean number of facebook posts is 38 per day perus national health authority has the largest number of posts per day with almost 13 compared to costa rica which posts with a lower frequency for each post the favorite option of followers is to click the like button followed by the possibility of sharing in their network the leastused option is to comment on posts information on leading causes of death was searched in the text of posts during the period under study this exercise was to identify the most common interests of users and to determine whether national health authorities posted contents related to leading causes of death in their countries information on the ten leading causes of death by country was also searched on each facebook profile including keywords and synonyms on average information on three of the ten leading causes of death was posted on the national health authoritys facebook site twitter sixteen out of the 18 countries under study have institutional presences through their national health authorities on twitter the countries with the highest proportion of internet users who follow national health authority profiles on twitter are ecuador el salvador and peru representing 102 055 and 066 of the total population of those countries respectively uruguay guatemala and bolivia are the countries with the smallest number of followers in relation to the population with internet access representing 006 002 and 004 of the total population of those countries respectively the information about the population with internet access following national health authorities by country on twitter is included in additional file 4 the average number of tweets per day is 71 the national health authority with the largest number of posts per day is venezuela with a mean of 191 tweetsday compared to costa rica which posts 01 tweetsday for each message sent through twitter the preferred option of users is to retweet a message rather than mark it as a favorite specifically the average of favorites per tweet is 26 and the mean for retweets per tweet sent is 33 the average number of all messages retweeted and marked as favorite per tweet is 59 information posted by national health authorities on leading causes of death was searched on twitter with the same methodology used for facebook each twitter profile was searched for the 10 leading causes of death by country including keywords and synonyms on average users were able to access information on 29 of the 10 leading causes of death posted on the national health authoritys twitter profiles youtube twelve of the 18 national health authorities of the countries analyzed have a presence on youtube the average number of videos analyzed per channel was 313 the average number of views per profile was 1 million and the average number of views per video was 4500 analyzing the content of the most viewed videos for the period studied 3 of the 12 youtube profiles analyzed shared videos addressing some of the 10 leading causes of death affecting their countries socioeconomic status and social media internet accessibility rates are lower in poorer countries concentrated mostly in subsaharan africa and parts of asia including 39 in nigeria 30 in indonesia and 22 in india in latin america a median of 64 of the population has access to the internet with the highest rates in chile and argentina 23 specifically for the 18 countries targeted in this study the median internet penetration is 446 6 one study suggested that individuals with different levels of socioeconomic status vary in the heuristics and search patterns they rely upon to direct their searches the researchers found that people with limited resources may be disadvantaged when turning to the internet to make a health decision 24 in our research socioeconomic variables were also considered to identify whether the socioeconomic status of different countries correlates with reach in social media platforms countries like mexico argentina peru chile and colombia are among the ten countries with the widest reach in social media sites thus leading to the conclusion that no correlation exists between social media reach and income levels 7 another variable considered was whether a correlation exists between public health expenditure and the possibility of retrieving information on the leading causes of death through social media the aim was to show whether public health expenditure is a limitation to having good visibility in each countrys content on social media seven of the 11 countries whose public health expenditures are below the mean exceed average information retrieval on the 10 leading causes of death on facebook and twitter on the other hand 6 out of the 7 countries that surpass average public health expenditures do not reach the average of information retrieval on their 10 leading causes of death in facebook after calculating the pearson correlation coefficient the result shows an inverse correlation for facebook and twitter visàvis public health expenditure and the possibility of finding information on the leading causes of death for a country with a presence in both aforementioned networks the correlation is negative in the case of facebook it is r 54 p 03 and for twitter it is r 26 p 31 discussion internet penetration there is a digital gap in internet penetration in latin america particularly in the countries under study where we can find countries with an internet penetration higher than 70 and others with a penetration index that does not reach 20 and where median penetration is 446 in only five of the 18 countriesaccounting for 277 of the totalthe penetration rate is higher than 50 these countries are colombia venezuela uruguay argentina and chile poor technological infrastructure particularly regarding internet access may represent a regression concerning the use of social networks in the field of public health specifically an average of only 1 of the population with internet access across the 18 countries in this study follows national health authorities on social media which represents approximately 03 of the total population of the countries under study social media are widely used to search for healthrelated information they provide national health authorities with unique opportunities to satisfy the needs of the population to access health information by providing education and information to their followers in addition the sum of interactions with health institutions on social media can help the population seeking health information on the internet by offering reliable information in contrast to sites of doubtful accuracy 2526 fifteen out of the 18 countries under study have institutional presence on facebook through their national health authorities when the activity rate was below the mean the main reason was that the number of posts on those platforms was well below the average a priori it appears that there is no relationship between income levels and reach in social media sites nevertheless six out of the seven countries that surpass average public health expenditure do not reach the average of information retrieval on their 10 leading causes of death on facebook population with internet access following national health authorities on facebook and twitter based on the assumption that followers of national health authorities profiles on social media were born andor live in those countries on average 1 of the population with internet access across the 18 countries in this study follows national health authorities on social media which represents approximately 03 of the total population of the countries under study even though facebook is the most widely used social network in the americas 7 for the objectives of this study twitter is the social network in which the national health authorities have the most followers on twitter the mean number of the total population with internet access following national health authorities is 086 representing 033 of the total population of the countries under study with ecuador el salvador and peru being the three countries with the highest number of followers compared to the total population with internet access representing 102 055 and 066 of the total population of each country respectively in the case of facebook the mean number of the population with internet access following national health authorities is 079 which represents approximately 028 of the total population of the countries in this study costa rica panama and peru are the countries whose national health authorities have the most followers representing 147 064 and 044 of the total population of each country respectively this study provides a valuable perspective on which countries have the best opportunity to influence their communities based on the content shared in the six countries where at least 08 of the population with internet access follows national health authorities on facebook information on one or none of the leading causes of death can be retrieved in four countries namely costa rica panama ecuador and argentina in the case of twitter the countries in the same situation are ecuador costa rica and panama although it is possible that health authorities in these countries can reach the population with their messages it seems that they are missing the opportunity to share countryspecific information on leading causes of death with a large audience the information about the population with internet access following national health authorities by country on facebook and twitter is included in additional file 4 the number of messages posted on twitter by national health authorities is almost twice that of messages posted on facebook an average of 71 tweets is posted daily compared to 37 posts on facebook nevertheless the number of interactions per post elicited by these messages was 1476 on facebook versus 59 on twitter activity rate of users and information retrieval on facebook and twitter another variable to consider regarding the number of interactions is the activity rate of users defined as the total number of interactions divided by the total number fig 6 percentage of population with internet access following national health authorities on facebook and twitter of followers on facebook these interactions are like share and comment and on twitter favorites and retweets this rate can identify activity as well as the strength of the relationship between followers and national health authorities it also helps to define the countries in which national health authorities can have a greater influence on health decisionmaking due to the relationships existing between users and authorities a higher activity rate implies an increased possibility to influence the public health of an active community interested in interacting with the contents produced by national health authorities a comparison of activity rate and information retrieval on facebook and twitter is included in additional file 5 on facebook the countries with the highest user activity rates are honduras peru and mexico the countries with the highest user to national health authority rates on twitter are honduras uruguay and venezuela when the activity rate on facebook was below the mean it was observed that the main reason for the low activity rate was that those profiles had posted well below the average which was 692 posts per profile it was not possible to identify such a pattern with twitter this may be due to the different ways in which these social media work as previously observed there is no doubt that the impact of a post on facebook is higher than on twitter and that users spend less time on twitter than on facebook and it follows that the possibility of interaction between users and national health authorities is also lower a tweet can rapidly fade out based on the time users are connected to twitter and on the number of people followed by users thus making it difficult to identify potentially relevant messages or those of interest for users still more research is needed to interpret the greatest number of interactions on facebook versus twitter beyond the possible relationship between a greater number of interactions when there are more publications taking into account the analysis of information retrieval on causes of death posted by national health authorities in their institutional profiles on facebook and twitter and the analysis conducted about activity rate on social media two of the three countries exceeding average information retrieval on causes of death on facebook paraguay and colombia have in turn an activity rate exceeding the average for the countries under study this means that the followers of these profiles on facebook have a higher chance of accessing contents on the leading causes of death in their countries the cases of peru mexico and chile having activity rates of 31 27 and 21 respectively are similar if the activity rates of these countries on social media are considered and assuming that followers are involved with healthrelated issues there is a higher chance of promoting a particular behavior or call to action on a particular issue on the other hand it is worth mentioning the case of honduras which has the highest activity rate but is currently among the countries with retrieval of information for one or none of the leading causes of death since it was not possible to retrieve information with the selected search strategies for honduras sharing information on causes of death could have a greater beneficial impact on the community compared to other countries where community activity is lower therefore the capacity to impact the behavior of the population is also lower something similar to facebook occurs on twitter honduras and venezuela two of the three countries with an activity rate higher than the average only offer information on three of the 10 leading causes of death on twitter attention should be given to the possibilities of both countries positively influencing their twitter community by making information on leading causes of death in their countries available socioeconomic impact aspects such as cost reduction and high internet penetration might explain why countries such as mexico argentina peru chile and colombia are among the 10 countries with the widest reach in social media platforms 23 the existence of an apparent negative correlation between public health expenditure and the number of the leading causes of death that can be found on facebook could suggest that for those countries in which the average public health expenditure is not exceeded social media platforms could be considered lowcost tools used to reach the public further research is needed to provide evidence that more dedication to health promotion interventions through social media could significantly improve the impact and the reach of public health messages and initiatives on the population conclusions the large number of institutional profiles on social media shows that national health authorities are aware of the relevance of having a presence on social media nevertheless national health authorities can still improve in terms of the role they can play and their participation in conversations on social media regarding the leading causes of death that affect their countries the analysis conducted shows that facebook can be a useful tool for health promotion interventions taking into account the penetration level of the internet in the countries under study more dedication to public health expendituresmainly in those countries with public health expenditures above average but with a low possibility of retrieving information on leading causes of deathfor health promotion interventions through social media could significantly improve the impact and the reach of public health messages further research is needed to know the exact budget allocated to this type of intervention as well as to identify and compare penetration to other traditional interventions such as press radio andor television finally some recommendations for policy makers based on this paper are along with national statistics agencies perform an exhaustive analysis of the population connected to the internet mainly considering the variables of age and sex including questions about the use of social media or queries about health on the internet this will allow better planning of measures regarding health messaging including the composition of messages with proper language and aimed at the appropriate audience based on the data obtained appraise the use of the social network twitter as one of the main communication platforms in emergency and disaster situations including everything related to health alerts moreover consider the social network facebook as one of the main platforms to reach out to the population for community building and development mainly at the time of raising awareness of the population in terms of public health campaigns promoting and participating in conversations on social media may help to improve institutional image and to discover what people think of the services offered by health institutions nontraditional communication channels can help to improve the quality of information that can be shared and can keep that information up to date we suggest reviewing the vocabulary used when referring to publichealthrelated terms particularly to ensure overall consistency as well as to facilitate information retrieval this review should consider whether the terminology used is the same the public would use taking into account that it would be citizens who will finally need to consult and receive advice on the content additional files additional file 1 list of keywords and synonyms on leading causes of death used authors contributions dno carried out the study and drafted the manuscript under the direct supervision of thp dno and thp participated in the study design analyzed and interpreted the results and revised the manuscript all authors contributed to read and approved the final manuscript competing interests the authors declare that they have no competing interests consent for publication not applicable ethics approval and consent to participate not applicable

background information and communications technologies like social media have the potential to reduce some barriers in disease prevention and control in the americas national health authorities can use these technologies to provide access to reliable and quality health information a study was conducted to analyze availability of information about the leading causes of death on social media channels of national health authorities in 18 spanishspeaking latin american and caribbean countries methods we gathered data of national health authoritiess institutional presence in social media exploratorydescriptive research was useful for analysis and interpretation of the data collected an analysis was carried out for 6 months from april 1 to september 30 2015 results sixteen of the 18 countries studied have institutional presences on social media national health authorities have a presence in an average of almost three platforms 28 an average of 1 of the populations with internet access across the 18 countries in this study follows national health authorities on social media approximately an average of 0 3 of the total population of the countries under study on average information on 32 of the 10 leading causes of death was posted on the national health authorities facebook pages and information on 29 of the 10 leading causes of death was posted on their twitter profiles additionally regarding public health expenditures and the possibility of retrieving information on the leading causes of death an apparent negative correlation exists in the case of facebook r 13 54 p 03 and a weak negative correlation in the case of twitter r 14 26 p 31 for the countries with presences in those networks conclusions national health authorities can improve their role in participating in conversations on social media regarding the leading causes of death affecting their countries taking into account internet accessibility levels in the countries under study and the high rates of people using social networks in even the poorest countries further research is needed to provide evidence that more dedication to health promotion interventions through social media could significantly improve the impact and reach of public health messages and initiatives

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introduction for people living with hiv in resourcelimited settings participation in longitudinal health studies often involves a series of interpersonal interactions and exchange of material resources and information repeat interactions with research staff occur in clinical settings through mobile phones in participants homes and in the community others have documented close relationships that can form between study participants and research staff in subsaharan africa and the ethical and practical challenges that these relationships can create 1 2 3 4 5 participants may encounter one another during study visits or at studywide events 6 participants also usually receive reimbursement for studyrelated activities and compensation 7 the manner in which participants ascribe value to their relationships with study staff and other participants and perceive of reimbursements and compensation has been incompletely examined yet it is essential to understand how these relationships and material exchanges shape enrollment retention studyrelated behaviors data collection and data interpretation moreover for plwh who participate in research understanding how the research environment creates and facilitates social interaction and exchange can provide insight into these individuals health and wellbeing social support refers to the provision of psychological and material resources by people within ones social network 8 research from resourcelimited settings has explored how individuals commonly depend on others for support and engage in communitylevel resource sharing 9 studies from these settings have shown that social support can arise from a variety of sources such as from friends and family as well as from communities of people who share common conditions like hiv 10 in uganda where our team was involved in a longitudinal antiretroviral therapy adherence monitoring study from 20052015 social support has been shown to help people living with hiv overcome barriers to receiving hivrelated care such as chronic food insecurity and the cost of transport to clinics 11 12 13 receipt of social support has also been linked to decreased hivrelated stigma 8 and improved art adherence 14 meanwhile increased availability of mobile phones has made access to healthrelated social support more available to individuals receiving longterm therapies in uganda 15 in this paper we examine how participants in a longitudinal art adherence monitoring study derived social support from study participation the ways social support was tied to studyrelated relationships and the implications studyrelated social support has for research conduct and data interpretation methods we conducted a qualitative study of participants enrolled in a longitudinal cohort study that monitored adherence to art in southwest uganda and of research assistants for the study our primary aim was to understand ethical considerations related to adherence monitoring which we have described elsewhere 16 17 18 in this manuscript we analyze social support that participants derived from study participation which was an emergent and unexpected finding of our study parent study the uganda aids rural treatment outcomes study was a longitudinal observational cohort study of art adherence in mbarara ugandaa city in the southwestern part of the country all participants received hivrelated care and free art through the mbarara regional referral hospital immune suppression syndrome clinic 19 in the uarto study electronic adherence monitors were used to characterize art adherence uarto participants were permitted to participate in uarto even if they opted to not use the eam following enrollment meaning that there was a subset of uarto participants who were eam nonusers uarto participants were typically seen in the iss clinic every one to three months per recommendation from their treating clinicians they also attended uarto study visits in a building adjacent to the clinic every three to four months during study visits they completed questionnaires and provided biological specimens they were given a meal while awaiting study procedures and received an incentive at each study visitusually a bar of soap or a kilogram of sugar transportation reimbursement was also provided based on selfreported cost of travel to and from the clinic the uarto study team organized dissemination events during the study at which participants gathered to hear about results and receive thanks for their participation 6 uarto ras who were universityeducated residents of mbarara served as the main points of contact for study participants all ras were trained in ethical research practice and data collection ras generally followed a set of participants for months to years meaning that participants repeatedly interacted with the same ra during the study ras performed study procedures when participants came to scheduled study visits additionally ras made field visits to participants homes or other prespecified locations to draw blood in instances of nonadherence and to assess device functionality because uarto was designed to be observational ras were advised to refer healthrelated questions to the clinic staff study design and participants we conducted individual qualitative interviews with uarto study participants and ras because our overarching goal was to explore ethical considerations surrounding eam use we used a criterionbased purposive stratified sampling approach to recruit uarto participants who did and who did not use eams all participants were �18 years old currently receiving art and had been enrolled in uarto for at least 6 months we recruited 40 participants who were eam users and 20 participants who were eam nonusers these prespecified sample sizes were selected because they were anticipated to be sufficient to achieve thematic saturation 2021 uarto ras identified key informants who they thought would be able to provide diverse and rich insights about eam use interview participants were recruited by phone or in person during uarto study visits the study was explained to participants as a way to understand their experiences with eams all individuals who were approached to participate in interviews agreed to enroll in our study interviews with uarto participants were completed in two phases first we conducted exploratory interviews to elicit general impressions surrounding eam use and uarto study participation second we conducted focused interviews to investigate concepts derived from ethics theory 22 and from exploratory interviews we only recruited eam users in the exploratory phase of our study due to relatively low number of eam nonusers in the uarto study eam users who participated in exploratory interviews were not included in focused interviews in addition we conducted indepth interviews with uarto ras to contextualize participants interviews interview guides are provided in s1 file thematic saturation was assessed during review of interviews as the interviewing process was ongoing and again during analysis of themes following completion of interviews based on these assessments we determined that we had achieved thematic saturation data collection we interviewed uarto participants and ras between august 2014 and june 2015 after consenting to participate all participants completed brief standardized demographic questionnaires which were entered into a secured electronic database using research electronic data capture version 6 23 a ugandan researcher trained in qualitative interviewing who was not known to participants before the study conducted all interviews in runyankole the predominant language in mbarara all interviews took place in a private location near the main uarto research site and were digitally recorded interviews were then simultaneously translated and transcribed into english by the same ugandan researcher and were reviewed and discussed with an american researcher at time of transcription to ensure a shared concept of key terms and ideas an american researcher trained in qualitative interviewing who was known to ras before the interviews but who was not directly involved in the uarto study conducted interviews with ras in english in a private research office interviews were transcribed in english data analysis we performed an initial inductive content analysis of exploratory interviews 24 participants in exploratory interviews described social support gleaned from involvement in uarto because the finding of perceived social support was unanticipated we further explored this concept in depth in focused interviews we used both inductive and deductive content analysis approaches to explore focused interviews initial analysis of both exploratory and focused interviews began with review and discussion of 20 of transcripts by american and ugandan researchers our initial transcript review aimed to identify content relevant to the primary ethical questions the study sought to answer and captured emergent themes related to the experience of study participation content was then organized as codes in a codebook initial codes captured data about the primary ethical questions explored during interviews as well as about emergent themes that arose in initial transcript review codebook development was iterative and involved defining codes and identifying representative quotes from transcripts to illustrate these codes codes were reviewed for common content and themes and were nested or merged when they were deemed to represent overlapping concepts the final codebook was then imported into nvivo version 11 and two american researchers coded all interviews discrepancies in coding were resolved by discussion among the team the process of developing codes the codebook and content identification was performed separately for exploratory and for focused interviews following coding of all transcripts codes were organized into categories in an iterative process that involved review of all coded text themes were derived by identifying relationships between categories organization of themes into social support categorizations and classifications was conducted during a series of meetings involving all members of the team during these discussions salient themes were identified as those that exemplified specific experiences of social support including emotional support and material exchange we compared responses of eam users from eam nonusers within codes and categories and found that eam users and nonusers experienced social support arising from study participation similarly results from these two groups are therefore presented together throughout the text ethical review the institutional review board at partners healthcare the research ethics committee at the mbarara university of science and technology and the uganda national council of science and technology reviewed and approved this study all participants provided written informed consent prior to participation the study and consent form were explained to participants in detail and the consent form was read to participants with limited literacy the consent process was conducted in runyankole with uarto participants and in english with ras results we interviewed 60 uarto study participants of whom 41 were women median age was 42 years most participants were literate and 20 had completed education beyond primary school we additionally interviewed 6 uarto ras median age of ras was 36 and 4 were female overview of qualitative findings participants described receiving multiple types of social support as a result of participating in the uarto study as shown in fig 1 we broadly classified experiences of linkage to medical care receipt of material support and health education as instrumental support we classified perceptions of feeling cared for social interactions and escape from stigma that participants experienced as emotional support participants highly valued the social support received through the study which often motivated adherence behaviors descriptions of social support did not differ between eam users and nonusers instrumental support uarto study staff connected participants to medical care unrelated to study participation for example although not a part of the studys design participants leveraged relationships with ras to get transportation to the hospital and to access clinical care for example there is a time i became sick at home and i called ras name on the phone and told him that i am sick he drove and came he took me to the clinic for the staff they took off blood from me and he took me back home he told me that he would bring me drugs art and the results after if i had not enrolled in the study i would not have met someone like ra ras also aided participants to access the iss clinic and the hospital more efficiently for instance ras facilitated transportation to and from the hospital welcomed participants and enabled participants to bypass lines and avoid long wait times at the clinic yes at times you realize that they want to confide in us their secrets for example someone tells you that she is pregnant but she does not want the husband to know so they seek your advice participants also explained that participation in uarto helped them understand the value of art adherence this educational messaging which was not a part of the uarto protocol became an ancillary feature of study participation and encouraged some participants to adhere to art she ra keeps telling me to think about how i used to be and how am now and this encourages me to keep taking my drugs well so that my health can be good she emphasizes to me the importance of taking my drugs and tells me to see it as something very important corroborrating these observations one ra noted i think they have gained knowledge and self confidence and responsibility from the questions we ask them in the study participants viewed transportation stipends incentives and meals that uarto provided as material support which was at risk when the study closed respondent i like everything about it in fact when they told us that its ending i felt very bad because they have been offering me counselling and support interviewer tell me more about this support r they have been giving me transport refund whenever i have been coming here to change the battery of the eam or to do a blood draw they have been also giving me a kilo of sugar a bar of washing soap this material support contributed to the relationships between research staff and participants participants explained that the incentives distributed by ras represented the uarto studys tangible commitment to their wellness r i like it because i have not seen any problem with it especially for us as women at times we can be there hard up and they come and bring us some support additionally participants expressed that the incentives were a reflection of being treated well by the research staff ras name is a good person she used to come and bring me incentives and she would send me a car to pick me at times she would even also interview me at times she brings me anything that is there for us in the project like sugar and soap she gave me a phone the device eam and incentives so i have not missed anything from the study and yet there are other people who are greater than me and who wanted to be in the study and get these things i mentioned but they did not get the chance so i thank my ra she is a good person and our relationship is good uarto participantation fostered communities of plwh that enabled participants to provide instrumental support to each other for instance one participant described a savings group that included other uarto participants this savings group functioned as a safety net providing transportation funds to meet extra costs of care i tell me about your involvement in the uarto study i r it helps me to associate with other people who are hiv positive and this helps me to learn that am not alone and i get encouraged for example in my area we are 157 people living with hiv some of them are in uarto study while others are not but they are getting their medication from mbarara hospital we formed our savings group where each one of us saves 5000 uganda shillings only approximately 170 us per month and this money is used to help in case a member needs to come to mbarara for medical care and they do not have transport so being involved in the study has helped me to associate with others we know each ones return date and we follow each other up to go for review and in case if one has no transport we provide it from the pool of money that we contribute per month in sum multiple forms of instrumental support were highly valued by study participants and acted as meaningful motivation for selfcare including adherence to art emotional support participants felt that ras diligence in conducting study procedures demonstrated care and a commitment to participants longterm wellbeing i know if i do not swallow they will know and call me an ra explained i actually they participants look at us as more than ras they look at us as someone to solve all their problems actually one participant called me and said ras name you have taken long without visiting me you should find some time and come and visit me knowing that you are there also somehow helps them to take their medication likewise participants felt that ras were concerned about their health which motivated them to adhere to art ra used to come and visit me and check on the device eam she would ask me how am i feeling so i would see that she feels concerned about me now if someone is concerned about you like that why you shouldnt also try to be concerned to take your drugs well so i see their ras responsibility is that they visit us and encourage us to take our drugs well and in time our interaction with the researchers is really good participation in the study was also perceived as a positive distinction among other clinic attendees they the study picked me out of many people and i feel special in fact others complain why they care about us who are in the study more so this gives me a feeling of connection to the clinic through participation in uarto participants frequently interacted with study staff and other research participants who were aware of their hiv serostatus this community of staff and study participants attenuated hivrelated stigma when i joined the study it helped me take away stigma because it helped me to disclose to some people i never would have disclosed to but when i met them in the study it helped me to disclose to them when i come to the clinic i also see people who are looking good and so i know that if i continue taking my drugs i will be like them an ra noted they have enjoyed interaction with different people in the study and people in the clinic and it has reduced sigma study visits provided an opportunity for participants to share information and interact informally participants gained emotional support and encouragement by sharing experiences of living with hiv in their communities encouragement often took the form of health advice given participants preoccupation with health and wellbeing if they tell me that it cd4 count has reduced i feel very worried but when i share my worry with other participants on the bench at the clinic they encourage me and advise me on how i can increase my cd4 count basing on their experience what foods to eat like fruits and vegetables it has been good to me because it put in me confidence it put in me selfesteem and i found there other colleagues who gave me their testimonies of how they have improved because i was not among the first people to join but i got confidence that i must live and we are living together with the instrumental support achieved through study participation emotional support from ras and other participants bolstered selfworth and motivated art adherence and achievement of good health discussion in this qualitative study of participants enrolled a longterm observational art monitoring study and the ras working closely with them we learned of the importance of social support that participants gained through longitudinal study participation support was both protocoldirected and unintended by the study unintended support derived primarily from close relationships that formed during repeated interactions with research staff and frequent connections with other study participants although broadly characterized social support has previously been identified as arising from study participation in subsaharan africa 25 our results enable a contoured understanding of the origins categories and depth of support these insights have implications for 1 investigators seeking to understand sources of bias in their data and the social context from which their data arise 2 ethics boards aiming to assess recruitment consent and costbenefit ratios of studies and 3 participants who are fundamentally affected by support they glean through engagement in research participants perceived linkage to healthcare as a major source of studyderived support enhanced access to clinical services arose both through transportation to the clinic and through streamlined navigation of the clinical intake and medication dispensing process other qualitative studies of research participants in subsaharan africa have identified healthcare access as a driver of study enrolment and retention in a mixedmethods substudy of a large trial in south africa and kenya that sought to explain trial participants low adherence to hiv preexposure prophylaxis 93 of participants indicated that they continued to participate in the trial because of the ancillary healthcare benefits the trial provided despite not wanting to use prep 26 kingori details the empty choice that research participants in subsaharan africa may face when given the option to participate in research due to improved medical care and other structural benefits afforded by research studies 4 although our participants did not describe feeling pressured to participate in research to gain access to medical care their perception of enhanced access raises questions about whether healthcare access should be presented as an explicit benefit of study participation in the consenting process additionally expectations of enhanced access may not always be met understanding what forms of support participants anticipate receiving from a study and the extent to which those expectations will be met could ensure that consent is truly informed although the uarto study protocol indicated that ras should refer healthrelated questions to the clinic staff health information was still conveyed through routine interactions participants often viewed ras as health authorities who they could easily approach to receive a wide range of health advice additionally despite the studys intention to observe adherence participants felt motivated to adhere to art in order to maintain relationships with research staff and thus sustain the emotional support these relationships created as we have described elsewhere 17 the extent to which social support affected adherence is an important outstanding empirical question our results indicate that observational studies in which studyderived social support can affect observational outcomes may need to measure and account for these effects in order to validly interpret results material support from the study in the form of transportation stipends meals and incentives were both valued unto themselves and perceived as a form of commitment to participants wellbeing transportation costs often impede access to hivrelated care in subsaharan africa 27 and transportation reimbursements have been found to improve hivrelated care 28 others have argued that transportation reimbursements or incentives function as a form of payment for research participation and data 2930 our participants tended to view transportation refunds incentives and meals as gifts rather than as payment as in prior studies participants attached feelings of care and connectedness to the tangible incentives and reimbursements they received 29 the research ethics community has struggled with balancing incentives against the prerogative to avoid undue inducement for study participation 31 meanwhile others have argued that providing material benefit is one of researchers ethical responsibilities in resourcelimited settings 32 our results underscore the emotional valence of material support for participants although the emotional aspects of receiving support are are difficult to quantify they merit researchers consideration when designing conducting and concluding studies that are ethical and culturally sensitive we also found that the uarto study created an environment in which participants could instrumentally support each other the formation of a community savings group that included uarto participants as well as the relationships that study participants formed with each other existed outside the realm of typical study benefit analysis nonetheless these groups and social connections were an important source of material support for participations in uarto investigators should remain vigilant for interparticipant support systems after studies commence since these systems may have a tangible effect on participants willingness to enroll and remain in studies moreover illuminating the social support networks that grow out of longitudinal studies is vital to understanding the context in which research data are generated and the broader effects of research studies on the communities they take place in empirically the longevity of these organicallyformed groups warrants investigation particularly after research studies end participants interpreted both intended and unintended support as indications of care and as cornerstones of their relationships with research staff the importance of relationships that study participants form with research staff has been recognized previously and participantprovider relationships have been incorporated into a model of factors affecting hiv adherence trial retention 33 in qualitative research from subsaharan africa others have described how healthrelated and socioeconomic needs of research participants conflicted with research staffs roles as objective data collectors 2 3 4 our findings provide evidence from the vantage point of study participants rooted in durable relationships with research staff uarto participants experienced sustained emotional support from participation this support helped to mitigate salient psychosocial challenges in their lives such as hiv stigma relationships with other study participants also provided substantial emotional support hivrelated stigma and nondisclosure of serostatus have been identified as barriers to accessing social support in uganda and elsewhere 103435 the uarto study created a community of participants who had disclosed to each other while waiting on the bench for study visits in this setting participants could share stories encouragement and advice for living with the physical and psychological tolls of hiv the range and depth of social support that uarto participants received have three important implications for longitudinal study design and conduct in subsaharan africa with stigmatized populations as well as for longitudinal study participants more broadly • altered study behaviors and the hawthorne effect although researchers acknowledge the potential to influence behavior through observation our results indicate that social support received through the study may be a critical driver of behavior modification to understand the effects social support may have on behavioral study outcomes researchers should be aware of the ways participants perceive protocolized incentives and stipends the manner in which interactions with research staff generate unintended forms of support may promote behaviors that studies seek to observe • managing study closure the depth of social support that uarto participants received through participation suggests that they may have much to lose when observational studies by necessity come to an end participants who lack resiliency may be particularly susceptible to stressors when they lose support resulting from studies 37 our results emphasize the need for researchers to understand and anticipate the psychosocial effects of study closure on participants researchers should also be prepared to manage participants expectations about durability of support if negative consequence occur due to loss of social support at the end of a longitudinal study investigators and ethics review boards should plan to inform prospective participants about this possibility • riskbenefit social support derived from observational studies may function as a substantial benefit of participation it may also create strong incentive to enroll and remain in research studies these effects may be enhanced for individuals with stigmatized conditions living in resourcelimited settings investigators and ethics review boards should consider how potential benefits of social support should be included into the overall riskbenefit calculus of studies they could consider explicitly commenting on potential sources of support in consent forms and in discussions with potential participants we found that social support arose from standard often obligatory study procedures as such our results do not suggest that investigators should intervene to manipulate social support that organically arises from observational studies rather investigators should be prepared to address the consequences of its generation and potential removal since it may form a core component of the experience of participating in an observational study particulary among marginalized communities in resourcelimited settings our findings and these implications raise the need for additional empirical research first although a number of survey scales have been developed to measure social support none address the unique features of studyrelated support that our participants described developing validated measurement tools could better equip investigators to quantitatively estimate and compare support arising from studies second both qualitative and quantitative measures of social support could be used to estimate the effects of support on observational study outcomes measuring this potential source of bias could enable investigators to understand generalizeability of observational studies third poststudy research should address the longevity of studyrelated social support and potential consequences arising from removal of support when studies end lasting effects of studyrelated support may be invisible while a study is ongoing likewise changes in adherence behavior that arise as a consequence of studyderived social support may not last beyond study closure repeat measures of studyrelated behaviors after closure of intensive longitudinal observational studies could quantify the magnitude and kinetics of this effect fourth additional research is needed to determine the range of social support across different populations study types and contexts the magnitude of support received and the ways in which support is perceived undoubtedly vary between studies for instance studyderived social support may be less salient in research with nonmarginalized populations with populations without substantial resource constraints or in shortterm research that does not foster close relationships between staff and participants the ability to plan for the effects of studyderived support hinges upon further exploration of this phenomenon in different settings and populations the limitations of our study should be noted interviews were conducted with a homogenous population of plwh in southwest uganda and we did not purposefully sample participants to enable comparisons by gender age or other potentially relevant characteristics we only interviewed individuals who were actively enrolled in uarto and therefore we were unable to assess baseline amounts of social support that nonparticipant plwh receive from their communities and the iss clinic despite efforts to distinguish our team from the uarto study the interviewer may have been perceived as being affiliated with the uarto study potentially skewing interview responses towards what participants thought would be socially desirable in conclusion the range and depth of social support we identified have important implications for future observational study conduct our participants described the instrumental and emotional benefits that may arise from a study conducted with a vulnerable population in a resourcelimited setting anticipating and examining these externalities of study participation will be vital for understanding the outcomes of observational studies conceptualizing the choices that motivate study enrollment and retention and mitigating any unintended consequences when studies must of necessity come to an end for researchers who meet the criteria for access to confidential data supporting information s1 file interview guides

participation in longitudinal research studies in resourcelimited settings often involves frequent interactions with study staff and other participants as well as receipt of incentives and transportation reimbursements social supportreceipt of material and emotional resources from ones social networkhas been linked to antiretroviral adherence in subsaharan africa the extent to which social support arises from study participation its range and depth and its implications for observational study conduct have not been extensively describedwe conducted individual openended and semistructured interviews with participants in a longitudinal observational antiretroviral therapy adherence monitoring study in mbarara uganda participants were asked about their experiences in the longitudinal study and their interactions with research staff we also interviewed study research assistants ras deductive and inductive coding were used to identify content related to the experience of study participation codes were organized into themes and relationships between themes were used to develop overarching categoriessixty longitudinal study participants and 6 ras were interviewed instrumental and emotional social support emerged as pervasive and valued aspects of longitudinal study participation instrumental support that participants received consisted of enhanced linkage to

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the pursuit of gender equality is not only an ethical mandate but a fundamental human right essential to ensuring that men and women enjoy equitable opportunities across diverse aspects of life 3 these disparities manifest in the division of roles into public and domestic 4 public roles encapsulate incomegenerating activities outside the home 5 while domestic roles involve nonincomegenerating tasks within the household these role distinctions perpetuate societal stereotypes and gender biases however the impact of gender inequality transcends ethics it reverberates through economic social and cultural dimensions 6 as highlighted by the national population and family planning board of indonesia 7 these disparities are socially constructed and dynamic while economic growth appears promising it remains insufficient to uplift all segments of society especially those in underprivileged areas 8 women both globally and in indonesia bear a disproportionate burden of poverty and deprivation constrained by limited access to education employment opportunities healthcare and essential services 9 recognizing the gravity of these disparities the ministry of womens empowerment and child protection has stressed the importance of quantifying gender inequality 10 this quantification is achieved through the application of key indicators including the human development index and the gender development index 11 12 while the hdi quantifies human development it lacks the capacity to capture genderspecific disparities in quality of life 13 in contrast the gdi integrates the same indicators as the hdi but incorporates a gendersensitive lens 14 an gdi score closer to 100 indicates a narrower gap in human development between men and women 15 in the pages that follow this article ventures into the interplay between gender inequality as mirrored in the gdi and per capita expenditure in indonesia 16 the gdi offers a window into the extent of gender inequality in human development while per capita expenditure serves as a barometer of individual and household economic status 17 our goal is to navigate the complex relationship between these variables illuminating the farreaching ramifications of gender inequality on economic wellbeing and the broader social and developmental fabric our research embarks on a journey of exploration in this domain before we embark on our own study it is imperative to look to the literature landscape previous studies highlighted in the subsequent literature review have paved the way for our own investigation presenting both insights and limitations by dissecting the strengths and weaknesses of these studies we aim to set the stage for our research and uncover the gaps in the existing body of knowledge method before you begin to format your paper first write and save the content as a separate text file keep your text and graphic files separate until after the text has been formatted and styled do not use hard tabs and limit use of hard returns to only one return at the end of a paragraph do not add any kind of pagination anywhere in the paper do not number text headsthe template will do that for you finally complete content and organizational editing before formatting please take note of the following items when proofreading spelling and grammar literature review this section undertakes a comprehensive analysis of prior research efforts to explore the intricate dynamics of gender inequality human development and economic growth within the context of indonesia 18 19 each of these studies has contributed valuable insights to the subject matter yet each also carries certain limitations the critical examination of these strengths and weaknesses forms the basis for our own research and sheds light on areas necessitating further exploration one of the reviewed studies has advanced our understanding of gender inequality by offering an explanation that is notably accessible to a broad readership 20 21 however it is not without limitations insufficiencies in the clarity and transparency of the research methods employed pose a concern a detailed unambiguous elucidation of data collection and analytical processes remains notably absent moreover the discussion regarding the analysis methods utilized in this study remains obscured highlighting the imperative need for a clear explicit methodology within the domain of gender inequality research 4 22 transparency and comprehensive methodological disclosure are integral to ensuring the credibility and replicability of findings another study significantly contributes to the exploration of the relationship between gender inequality and economic growth 23 24 a key strength lies in its utilization of data from a reputable source thus augmenting the credibility of the research furthermore the studys analysis extends across various related fields affording a comprehensive overview nonetheless this study harbors limitations its exclusive focus on a specific region to the exclusion of a broader national context hinders the generalizability of its findings it is imperative for future research endeavors in this domain to transcend regional boundaries and encompass a more diverse spectrum of indonesian regions to ensure a holistic understanding of the national landscape the study that elucidates the influence of gender inequality on the survival strategies of impoverished farmworker households in a specific village 25 is distinctive for its lucid and wellstructured research methodology however its limitations are conspicuous notably several critical indicators essential for a comprehensive understanding remain insufficiently explained this shortfall creates gaps in the researchs comprehensiveness underscoring the necessity for thorough indicator explanations to facilitate robust insights another study distinguishes itself through the profusion of clear wellreferenced materials substantially bolstering the credibility of its research 26 the presentation of research findings is notably clear and accessible nevertheless this study exhibits weaknesses particularly concerning data visualization the utilization of dot points results in unclear data visualization potentially impeding comprehension and impairing the effectiveness of data representation streamlining the data visualization process holds the potential to enhance the researchs clarity and impact a different study benefits from numerous supporting references that buttress its credibility 27 nevertheless it possesses notable weaknesses in terms of its analysis methodology data visualization and the lucidity of its conclusion the analysis methodology remains incomplete and vague potentially undermining the replicability of the research furthermore a dearth of data visualization detracts from the accessibility and comprehensibility of the researchs findings the conclusion of this study falls short of effectively representing the researchs results emphasizing the pivotal importance of crafting clear comprehensive conclusions within the domain of gender inequality research in summation the extant body of research on gender inequality in indonesia has enriched our understanding albeit marked by notable limitations addressing these limitations while fostering a deeper understanding of the intricate interplay between gender inequality the gender development index and per capita expenditure remains the primary objective of our research this involves advancing a meticulous methodology comprehensive data analysis and transparent data visualization among other improvements to promote a more comprehensive examination of this critical subject data collection data collection is a critical phase in this study forming the cornerstone upon which our subsequent analysis is built in this context we categorize data sources into two primary types primary data and secondary data • primary data constitutes information gathered through direct empirical research involving individuals or entities directly engaged with the subject under investigation 28 this approach relies on three primary data collection techniques 29 observation as the name suggests involves the direct and systematic observation of the object or subjects central to our study this method affords us the opportunity to gather realtime insights and firsthand data providing a rich source of information interviews are structured questionandanswer sessions conducted with individuals who hold authoritative positions or have direct involvement in the research subject this technique allows us to tap into the expertise and perspectives of key figures related to our study questionnaires are instrumental in collecting primary data these tailored lists of questions are distributed to respondents closely linked to the subject matter offering a structured approach to data gathering • on the other hand secondary data comprises information obtained from external sources or research conducted by third parties secondary data sources prove invaluable as they provide insights into the research topic without necessitating direct interaction 30 for our study secondary data sources are curated from trusted repositories such as the unpas repository the data collection techniques deployed in this study are tailored to the research objectives • field research is a fundamental approach designed to procure primary data directly this encompasses three key methods observation which offers the unique advantage of providing a realtime firsthand perspective by directly observing the subject matter within its natural context interviews with pertinent authorities and individuals closely connected to our research focus these structured questionandanswer sessions enable the collection of primary data and insights from key informants questionnaires are a structured tool allowing us to gather primary data by posing a series of questions to respondents directly affiliated with the subject matter • library research serves as a vital avenue for collecting secondary data it involves an indepth exploration of relevant literature and books linked to our research subject this approach allows us to tap into the theoretical foundations that underpin our study • internet research is another significant data collection technique it entails the collection of data from websites and online sources that are pertinent to our research topic this method provides access to a wealth of online information which is particularly valuable in the digital age the culmination of these data collection techniques and methodologies will enable us to acquire a comprehensive dataset for our study this dataset will serve as the basis for our indepth analysis of gender inequality in indonesia concerning human development index and per capita expenditure measurement of gender equality the measurement of gender equality is a pivotal aspect of this study enabling us to gauge disparities in the context of the human development index and per capita expenditure 12 27 a meticulous assessment of these measurements helps provide a comprehensive understanding of gender inequality in indonesia the ministry of womens empowerment and child protection offers guidance on how to ascertain gender inequality chiefly by examining the gap between the gender development index and human development index values the gender development index is a central metric in our analysis it represents the ratio between the hdi values of women and men 31 32 this index varies between 0 to 100 percent where a higher gdi value indicates a narrower development gap between men and women in essence gdi much like hdi is influenced by key components encompassing life expectancy literacy rate average years of schooling and per capita expenditure these elements are integral to understanding the dimensions of gender inequality in indonesia gender equality and justice are of paramount importance in the indonesian context the government of the republic of indonesia has taken significant steps to address gender inequality evident through the issuance of presidential instruction number 9 of 2000 on gender mainstreaming in national development gender mainstreaming is a central strategy in the formulation and evaluation of national development policies and programs however despite these efforts gender prejudice still persists in numerous facets of life women continue to face discrimination in terms of equal rights access to education and healthcare resources employment opportunities and political engagement in our analysis we aim to explore the relationship between gender inequality and key indicators particularly hdi and per capita expenditure the gdi provides a robust framework to assess these disparities as it delves into the differences in the development achievements of men and women thus shedding light on the extent of gender inequality in indonesia our investigation employs a combination of statistical methods including hypothesis testing and thematic mapping to quantify these disparities and present a comprehensive picture of gender inequality the results of this analysis will not only contribute to a deeper understanding of the challenges faced by women in indonesia but will also provide critical insights for policymakers and stakeholders to craft targeted interventions aimed at addressing gender inequality descriptive analysis in this section we delve into a comprehensive and detailed analysis of the data aiming to provide a profound understanding of the gender disparities in the human development index and per capita expenditure in indonesia descriptive analysis is a fundamental step in this process serving as the bedrock upon which our subsequent statistical investigations are built 33 • frequency distribution 34 is the initial facet of our descriptive analysis this involves organizing the data systematically into categories rendering it comprehensible and facilitating insights into the distribution of hdi and per capita expenditure across different genders we explore various types of frequency distributions such as ungrouped frequency distributions rank order distributions grouped frequency distributions and distribution graphs these different representations offer nuanced perspectives on the data shedding light on its inherent patterns and disparities • central tendency measurement is crucial for pinpointing the central values within our dataset measures of central tendency including the mean median and mode provide insights into where the data cluster most frequently this analysis unveils the average middle and most frequently occurring values allowing us to understand the typical values of hdi and per capita expenditure for each gender 35 this information is critical in determining the central position of these variables and helps identify whether there are significant deviations from these central tendencies indicating disparities • variability measurement aids in comprehending the degree of dispersion within the quantitative data by calculating interquartile range quartile deviation mean deviation standard deviation and coefficient of variation we assess the variability of hdi and per capita expenditure variability measurements offer critical insights into the homogeneity or heterogeneity of the data informing us about the spread of data points understanding the variability is pivotal in assessing the degree to which data points deviate from the central tendencies helping to identify disparities and outliers • mean which is a vital component of our analysis offers a detailed assessment of the typical values of hdi and per capita expenditure 36 by calculating the mean we gain insights into the average hdi and per capita expenditure for each gender providing a quantitative measure of what can be considered the norm within our dataset 𝑀𝑒𝑎𝑛 ∑ 𝑥 𝑖 𝑛 𝑖1 𝑛 • standard deviation and variance provide a comprehensive understanding of the spread of data points these metrics help quantify the extent to which data points deviate from the mean a high standard deviation and variance signify significant disparities within the data indicating the presence of outliers and deviations from the norm by assessing these measures we uncover the degree of variability in hdi and per capita expenditure and identify genderbased disparities 𝑠 2 ∑ 2 𝑛 𝑖0 𝑛1 𝑠 √ ∑ 2 𝑛 𝑖0 𝑛1 in this analysis we consider four types of data nominal data ordinal data interval data and ratio data each data type is assessed in accordance with its characteristics revealing the various dimensions of gender disparities in hdi and per capita expenditure understanding the data types aids in selecting appropriate measures of central tendency and variability the analysis extends to evaluating the significance of genderbased disparities and understanding the implications of these disparities on human development and economic wellbeing this detailed descriptive analysis sets the stage for our subsequent statistical tests and thematic mapping offering a robust foundation for understanding gender inequality in indonesia ttest analysis in this section we dive into a comprehensive and indepth analysis using the ttest a statistical method that allows us to rigorously assess whether there are significant differences in the human development index and per capita expenditure 37 38 between genders in indonesia the ttest is an indispensable tool for investigating the significance of gender disparities in these key indicators the ttest serves as a crucial means of determining the presence of statistically significant disparities it is particularly valuable when the conditions for the ztest are not met as is often the case when working with realworld data where population standard deviations are not readily available • ttest for equal variances this method is employed when the variances of hdi and per capita expenditure for men and women are assumed to be equal by conducting the ttest under these conditions we can ascertain whether there are significant differences in the means of hdi and per capita expenditure between genders the pooled ttest is a robust approach for investigating genderbased disparities in these critical metrics the formula for the pooled ttest is as 𝑡 𝑥̅ 1 𝑥̅ 2 𝑆 𝑝 √ 1 𝑛 1 1 𝑛 2 𝑆 𝑝 𝑠 1 2 𝑠 2 2 𝑛 1 𝑛 2 2 here x̄1 and x̄2 represent the sample means for men and women sp is the pooled standard deviation and n1 and n2 are the sample sizes for men and women respectively the degrees of freedom are determined as df n1 n2 2 • ttest for unequal variances in situations where it is inappropriate to assume that the variances of hdi and per capita expenditure are equal between genders we turn to the ttest for unequal variances this method allows us to investigate gender disparities in hdi and per capita expenditure while accounting for differing variances the formula for the ttest for unequal variances is as 𝑡 𝑥̅ 1 𝑥̅ 2 𝑆 𝑝 √ 𝑠 1 2 𝑛 1 𝑠 2 2 𝑛 2 here x̄1 and x̄2 represent the sample means for men and women s12 and s22 are the sample variances for men and women and n1 and n2 are the sample sizes for men and women respectively degrees of freedom are calculated as df n1 n2 2 by employing these ttests we can rigorously evaluate whether the disparities in hdi and per capita expenditure between genders are statistically significant this analysis goes beyond mere observation offering statistical evidence to support or refute the presence of genderbased disparities in these critical indicators the results of these ttests are pivotal in shaping our understanding of gender inequality in indonesia they provide quantitative insights into whether the disparities in hdi and per capita expenditure are substantial or if they can be attributed to random variation this deep analysis using the ttest enables us to draw robust conclusions regarding gender inequality and inform policy and interventions aimed at addressing these disparities proposed method our research methodology is meticulously designed to investigate and assess gender inequality in the human development index and per capita expenditure in indonesia it combines a series of welldefined steps to provide a deep and comprehensive understanding of the disparities between men and women • data collection and exploration our research leverages secondary data sources primarily drawing from the official website of the central statistics agency this trusted data source ensures the reliability and integrity of our analysis data exploration is a critical initial step during which we meticulously examine the gathered data visual assessment through box plots aids in identifying and subsequently removing outliers that could potentially compromise the accuracy of our analysis • descriptive analysis and hypothesis testing our research delves into a detailed descriptive analysis of hdi and per capita expenditure data this entails calculating fundamental descriptive statistics including means standard deviations and quartiles these statistics offer a comprehensive perspective on the distribution and central tendencies of these critical indicators for both genders hypotheses are formulated based on visual insights and subsequently subjected to statistical testing using the twosample ttest this rigorous analysis method assesses the statistical significance of disparities between men and women assuming equal variances • thematic mapping for spatial insights to gain spatial insights into gender disparities we employ thematic mapping a powerful visualization tool data is categorized into clusters denoting low medium and high disparities providing a clear regional overview of gender inequality in hdi and per capita expenditure this thematic mapping aids in identifying regions in need of targeted interventions and informs policy evaluations it paints a comprehensive picture of how these vital metrics are distributed across indonesia in conclusion our research methodology is structured to offer a comprehensive and rigorous analysis of gender disparities by combining data collection exploration descriptive analysis hypothesis testing and thematic mapping it equips us to investigate understand and address gender inequality in hdi and per capita expenditure ultimately contributing to informed policy decisions and interventions results and discussion in this section we delve deeper into the results obtained from the analysis of gender disparities in human development index and per capita expenditure in indonesia our examination comprises several subsections each offering a more detailed analysis of the findings hdi disparities between genders in this subsection we scrutinize the disparities in hdi between men and women in indonesia researchers initiated the analysis by visualizing hdi data through box plots to identify outliers the presence of outliers was evident in both mens and womens hdi data for the year 2020 these outliers potentially skewed data were systematically removed to ensure data integrity before proceeding with further testing visualizing the hdi data through box plots provided valuable insights into variations in the average hdi between men and women descriptive analysis was then applied to the refined hdi data which excluded outliers this statistical exploration unveiled essential insights into the hdi data with 58 hdi data points it became evident that the average hdi was approximately 717424 with a standard deviation of 40288 the data ranged from a minimum of 6297 to a maximum of 7927 the quartiles presented values of 68255 72285 and 75660 providing an indepth understanding of the datas distribution and central tendencies • hypothesis testing for hdi to ascertain whether a significant gender disparity exists in hdi we employed the twosample ttest with a critical significance level of 1 our hypothesis testing yielded a test statistic value of 101041 the pvalue shown in figure 1 is 3137x1014 consequently we confidently rejected the null hypothesis concluding that there is indeed a statistically significant difference in the average hdi between men and women in indonesia importantly the analysis revealed that the average hdi for men surpasses that of women per capita expenditure gender disparities in this subsection we explore disparities in per capita expenditure between men and women in indonesia researchers used box plots to visualize and identify outliers in both mens and womens per capita expenditure data for the year 2020 after the identification of outliers descriptive analysis was performed on the refined per capita expenditure data this analysis provided detailed insights into the characteristics of per capita expenditure data findings mirrored those of the hdi data statistics the per capita expenditure data consisted of 58 data points with an average of approximately 717424 and a standard deviation of 40288 the data ranged from a minimum value of 6297 to a maximum value of 7927 quartiles were measured at 68255 72285 and 75660 mirroring the datas distribution and central tendencies these statistics mirrored the findings for hdi offering a consistent perspective on per capita expenditure for men and women • hypothesis testing for per capita expenditure to evaluate whether significant gender disparities exist in per capita expenditure we applied the twosample ttest maintaining a critical significance level of 1 our hypothesis testing produced a test statistic value of 118892 coupled with a pvalue of 7465x10 this robust statistical evidence led us to reject the null hypothesis indicating a substantial difference in the average per capita expenditure between men and women the analysis demonstrated that similar to hdi the average per capita expenditure for men was notably higher than for women spatial distribution of gender disparities to gain a more comprehensive understanding of gender disparities in human development index and per capita expenditure we conducted spatial visualization using thematic maps these maps effectively cluster hdi and per capita expenditure into three categories low medium and high the aim was to identify regions with significant genderbased disparities and inform potential policy interventions • hdi thematic maps our thematic mapping exercise focused on comparing the hdi distribution between men and women as displayed in fig 5 the thematic maps revealed noteworthy disparities in the classification of hdi between genders notable differences emerged in several provinces including riau west sumatra central kalimantan north kalimantan central java east java central sulawesi south sulawesi and north sulawesi the disparities in hdi classification between men and women within these regions signify the persistence of gender inequality in terms of hdi • implications for policy the observed gender disparities in hdi within specific regions underscore the need for targeted policy interventions to address these inequalities it is crucial for policymakers to focus on these regions to enhance gender equality and ensure that both men and women have equal access to opportunities that contribute to human development • per capita expenditure thematic maps in addition to analyzing hdi we conducted a similar thematic mapping exercise for per capita expenditure by gender fig 6 illustrates the thematic maps revealing disparities between mens and womens per capita expenditure significant differences were observed in provinces such as aceh riau west sumatra jambi south sumatra central kalimantan south kalimantan east kalimantan central java sulawesi island and maluku notably the entire island of sulawesi showed a tendency for per capita expenditure to be dominated by women while riau and north kalimantan areas exhibited a preference for men these variations can be attributed to different cultural and socioeconomic factors • policy implications the disparities in per capita expenditure indicate that targeted interventions are needed in specific regions to address genderbased differences these variations can be attributed to cultural factors and demand tailored policies that address local needs and conditions as such policymakers should consider these findings in developing more equitable and effective strategies to reduce gender disparities in per capita expenditure policy implications and further considerations our study offers critical insights into the gender disparities in hdi and per capita expenditure in indonesia these findings hold significant implications for policymakers as addressing these disparities is paramount for ensuring more equitable economic growth gender disparities not only impact the welfare of women but also have wider implications for men and children as well as overall economic development existing policies related to gender equality in indonesia reveal both progress and challenges while the ratification of cedaw through law no 7 of 1984 marked an important milestone there is a need for more comprehensive and effective implementation of genderrelated policies alarming issues such as rising maternal mortality rates underscore the urgency of addressing genderrelated targets the work of gender activists ngos and civil society plays a crucial role in advocating for gender equality and challenging societal norms and biases it is clear from our research that ongoing efforts to reduce gender inequality are imperative furthermore policies should aim to address the issue not only at a practical level but also on an institutional and knowledge level the success of programs like mampu highlights the potential for change in indonesia expanding and adapting these initiatives at the local level is crucial to achieving lasting and meaningful progress in gender equality gender equality touches on all aspects of human life including the economic social cultural political and health domains achieving gender equality requires collaborative efforts from government civil society and the private sector recognizing its farreaching consequences in light of these findings it is clear that gender disparities in hdi and per capita expenditure persist spatial visualization in the form of thematic maps has identified regions requiring targeted policy interventions these maps highlight the necessity of tailored approaches to address gender disparities effectively our research emphasizes the importance of datadriven decisionmaking and multifaceted strategies to promote a more equitable society and foster economic growth it also underscores the significance of achieving gender equality not just for women but for the entire population and the nations development as a whole future research should further explore these disparities and assess the impact of policy changes on gender equality and economic growth in indonesia conclusion this research has provided critical insights into the genderbased disparities in human development index and per capita expenditure in indonesia the analysis using a combination of visual representations and statistical tests confirmed the existence of significant differences in both hdi and per capita expenditure between men and women men on average exhibited higher hdi and per capita expenditure highlighting areas where gender inequality persists these findings hold substantial implications for indonesia gender inequality not only affects individual wellbeing but also has broader economic repercussions hindering overall economic growth it is crucial for the indonesian government alongside regional authorities and stakeholders to prioritize policies that address these disparities targeted interventions in regions with significant gender inequalities as revealed by thematic maps can help to reduce these discrepancies and promote gender equality this research reinforces the importance of ongoing efforts to create a more equitable society and emphasizes the need for informed policymaking to effect meaningful change in the country

gender equality a subject of enduring global importance holds a distinct place within the national discourse of indonesia 1 despite the enactment of numerous international and national legal protections gender disparities persist deeply entrenched in cultural legacies and societal norms gender is a multidimensional concept encompassing differences in roles behaviors activities and socially constructed traits 2

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introduction companies that fulfill their purpose and responsibilities to stakeholders reap rewards over the longterm companies that ignore them stumble and fail larry fink ceo blackrock if marketers are to create a better world through socially responsible marketing they require a comprehensive roadmap of what that means and where it leads the enlightened proposition that community country and global betterment is an abiding goal of marketing demands a conscious social awareness and responsiveness on the part of marketers including marketing academics our analysis and discussion help demarcate the latitude and longitude of a doctrine of socially responsible marketing by proposing a comprehensive normative definition historically the idea of marketing being in sync with societal expectations has long been expressed in the idea of marketing practice being socially responsible writing in the journal of marketing william lazer opined marketing is not an end in itself…marketing must serve not only business but the goals of society it must act in concert with broad public interest both a major theoretical and practical problem regarding the idea of srm is that there never has been a significant consensus about exactly what the definition of socially responsible marketing includes as a result in practice the obligations of marketers to discharge their social duties and indeed even what duties those precisely consist of has been a debatable muddle at the extreme we still find a rigid interpretation and dogmatic embrace of some views expressed by milton friedman essentially the only social responsibility of business is to maximize profit within the law this narrow conception is a dubious and counterproductive notion to which we shall return given the uncertainty about the nature and scope of socially responsible marketing one chief purpose of this article is to bring greater definitional clarity to the concept of srm in constructing a literatureinformed and theoretically defensible definition of socially responsible marketing this ordered exercise specifies and elucidates the content domain that appears most fertile for framing testable propositions concerning srm this explication also provides a standard to judge responsible marketing from a societal standpoint without a rigorous normative standard of what constitutes socially responsible marketing the discipline of marketing is without the ability to evaluate whether social progress regarding the contributions of marketing toward a more ethically responsible world is even being contested the point when the meaning and properties of concepts are more commonly understood and accepted subsequent examinations are likely to reflect those understandings and integrate their implications into future analyses therefore the main purpose of this article is to articulate and justify a comprehensive definition of srm that marketing managers and academic researchers can utilize to evaluate and to improve ethical and socially compatible marketing general considerations why macro why normativeethical as this treatise involves explicating a definitionie bringing clarity to meaningwe should initially comment on the denotation and import of two key terms utilized in the title of this analysis macro and normativeethical this examination will be macro because understanding the nature of responsible better world marketing necessarily involves taking a societal perspective to this end the lens of macromarketing is employed because this line of academic inquiry examines the interaction of markets marketing and society dissecting socially responsible marketing implies that the strategies marketers select in administering their marketplace actions can shape potent societal outcomes both good and bad such examinations of marketsystem dynamics are the central wheelhouse of macromarketing inquisition and have been since the formation of the marketing discipline itself prior to the mid1960s looking at marketing questions usually involved examining both systemlevel and firmlevel considerations bartels in his history of marketing describes how the marketing discipline began by investigating institutional level issues such as the flow of agricultural products or the aggregate costs of distribution and while the precise moment when macro analysis began to wane in academic marketing research cannot be established the initial publication of kotlers marketing management textbook with its microfocus on the efficiency of marketing decisions at the company level seemed to elevate micromarketing to the ascendant concern most marketing issues were subsequently viewed through the prism of organizational comparative advantage to be clear social questions were still regularly raised and debated in marketing inquiryconsumerism social marketing green marketing but most often they centered on how such issues affected firmlevel marketing operations to address marketing issues at the systems level recognizing that existing networks of exchange might not be optimum such scholarly labors fell to fewer academics who eventually published in the journal of macromarketing although the micromanagerial perspective still recognizes the presence of exogenous macro variables it treats them as relatively uncontrollable factors to be managed and adapted to as best firms are able while macro analysis has declined in popularity for many academic marketing researchers we posit that successfully addressing the holistic nature of socially responsible marketing requires a renewed systemslevel emphasis this examination of srm is also normativeethical because value judgments must routinely be made regarding whether particular marketing campaigns practices and policies incrementally contribute to the common good ie when does marketing truly help create a better world does a particular marketing practice aid the general welfare is a specific marketing action socially benevolent alternatively stated some ethical standard of evaluation must be selected and applied before specific marketing practices can be judged to be responsible for societyie socially responsible marketing to argue the counterpointthat academic marketing research should be value neutralis itself a moral claim in 2014 ferrell et al reviewed the full domain of corporate social responsibility in marketing citing over 100 marketingcentric papers and reached the following conclusion about srm …many of the social issues consumer protection issues and sustainability concerns are equated with ethics therefore the assumption could be that the entire domain of csr and marketing deals with marketing ethics this means that both a normative and descriptive understanding of ethical decisionmaking that influences csr outcomes is important the explications of elements that are discussed below will dive deeper into the indispensable application of both a macro and normativeethical perspective in order to understand the nature of socially responsible marketing conceptualtheoretical approach the methodology of defining and delineating srm we utilized a conceptual theoryinformation method to postulate a normative definition of socially responsible marketing consistent with yadav who classified all conceptual articles appearing in the journal of marketing 1978marketing 2007 this this analysis falls into the realm of the context of discovery specifically into the category of switch ing the level of analysis to explore a…phenomenon this commentary takes a macromarketing perspective it also proposes a normative definition of srm that is literaturesupported philosophically grounded and ethically robust and why that perspective is wellsupported in the literature this requires deconstruction of current micro beliefs and a reconstruction of historical and contemporary macro insights concerning marketings abiding social objectives this whole effort can be characterized as philosophically validating an authentic definition of socially responsible marketing we describe the general process implemented and how this approach helps theoretically justify our postulated definition of srm in an endnote we encourage readers to review this process at this time in order to better understand the various facets of our definitional construction in summary by following the progression described therein we gauge that our definition of srm is grounded in a rigorous conceptual approach the challenge in following such an approach is to show how the definition of srm we postulate convincingly describes what normative srm ought to be based on a logical and defensible analysis of assorted literatures frameworks and theories found in macromarketing institutional economics management history and business ethics our referenced sources will necessarily include many booklength publications and socialissues related journals because these outlets have allowed the deeper exploration of bigpicture topics that command our speculative inquiry this technique is also prudent because as wilkie and moore contend in their meticulous analysis of the eras of marketing thought coverage of broad systemic marketing and society issues in alevel marketing journals has not been significant since the mid1980s to the possible detriment of the marketing theory and ironically the marketing profession presently as noted there is little consensus about the nature and purview of socially responsible marketing if this fact is not shocking it certainly should be considered deeply problematic for example langan reviewing 151 articles on csr in marketing identifies multiple economic ethical and philanthropic conceptions about the character of the srm thus following langans general classification an observer could argue from an economic efficiency standpoint csrmarketing is a discretionary business practice that should be undertaken when such actions are likely to contribute incrementally to marketing objectives or one might assert that srm is an ethical predisposition best reflected in the company mission statement to be consulted when formulating marketing policy alternatively some would contend that srm is best implemented by external and carefully targeted corporate philanthropy or voluntarism which then might improve companybrand reputation among customers and public each of these disparate views about srm has had its proponents as indicated by the citations but absent an agreed upon conceptualization of socially responsible marketing one is at a loss when trying to specify whether srm has even occurred to take a simple example if a large energy company with a stated commitment to responsible behavior in its corporate mission statement spends millions of charitable dollars to support promote and develop the performing arts but denies in its promotional literature that the companys resource extraction processes can degrade the physical environment is that organization a practitioner of srm in response one could sarcastically quip it depends upon where in the company one looks whom one asks and what one seeks from srm in sections below the social contract distributive justice and constructive engagement will be examined specifically as they vitalize a doctrine of srm drawing upon kuhn regarding the basic content of conceptual paradigms we envision this srm definition as an epistemology that will help inspire clarify and assess future propositions about the dynamics of srm and consistent with kumars advocacy about the development of theory in marketing this effort utilizes concepts extant theory and the relevant literature to refine conceptual thinking about the nature of socially responsible marketing therefore our discussion is intended to compellingly portray what srm consists of so that its key elements can be more confidently integrated in future studies and further debated regarding their efficacy in capturing the nature of responsible marketing expressed another way the specification of srm elaborated below should be a conversation starter in future discussions of …whether existing marketing approaches are being applied to their maximum potential whether turbulent environments call for new approaches for doing good whether any harm that marketing creates can be more effectively minimized… the upshot of the above discussion the definition of socially responsible marketing that is offered below is premeditatedly a normativeethical ideal moreover we recognize neither most marketing firms nor most mesolevel exchange systems will conform perfectly to that ideal for instance people are told to work diligently maintain healthy diets regularly exercise attend to family obligations contribute to their community along with assorted other desirata but it is difficult for most folks to do all those things consistently and well so too every marketing program does not contribute responsibly to a better world but on the balance marketing actions must be understood designed and measured to help achieve that ideal otherwise the marketing profession will be held in public contempt further regulated and could be found on the wrong side of history in this sense high ideals for marketing practice are indispensable thus the definition of srm offered below is by necessity a macro and normativeethical ideal against which sets of actual microbehaviors by marketers can be compared and analyzed in table 1 we summarize what each section of our article is designed to contribute from a perspective of theoretical definition construction interested readers are asked to consult this tablea synthesis of our selected approach and its literatureanchored backgroundwhich allows proceeding immediately to the formal postulation of our normative definition of socially responsible marketing and its conceptual context section i we register our normative definition of socially responsible marketing while definitions have evolved a majority are ephemeral descriptive and ad hoc they merely reflect the hypothesesfocused investigations of contemporary practices which are knowingly not intended to describe the totality of srm in contrast normative definitions can be more enduring they represent a broader relatively unchanging standardan ethical ought that implies a morally correct approach across a broad swath of situations they serve as an ideal and are grounded in a systematic logic rooted in the philosophy of science section ii srm is shown to be nondiscretionary as well as part of the necessary dna of accountable professional marketing practice if srm can be shown to be societally required via the social contract its practice in marketing becomes a categorical imperativean ethical action that must be taken sections iii to v the core definiens of srm corporate citizenship stakeholder orientation and socialecological sustainability are shown to be essential to the total understanding of srm for each element a thumbnail history is presented with some key literature from marketing and other disciplines that help add gravity to each concept consistent with the development of definitions the goal is to make the primitive elementsthe definiensless primitive and more amenable to eventual theory integration section vi explicates a specific macro normativeethical perspective rooted in distributive justice it provides a standard to measure the gap between marketing practice and its societal ideal without this evaluating the social contribution of marketing becomes a piecemeal and issuebound debate centered on the frequency and social impact of questioned marketing practices fairness is judged by the allocation of benefits and burdens to stakeholders section vii expands the macromarketing perspective by showing that constructive engagement can serve as a purposeful tool for making marketing decisions that augment social responsibility here our explication further establishes that any systematic theory of srm must also be macro in order to address institutional and systems level factors as well as to mitigate microlevel impediments to socially responsible marketing section viii specifies an abridged agenda of future scholarship and education to advance a firmer foundation for understanding the publicly expected role of marketing in society socially responsible marketing defined its context and composition socially responsible marketing consists of practices and perspectives mandated by an implicit social contract which requires marketing policies actions and outcomes to adhere to a corporate good citizenship that is proactive and nondiscretionary it is informed by a stakeholder orientation that recognizes an authentic consideration of stakeholder claims especially those of the customerconsumer and vulnerable stakeholders further srm seeks social and environmental sustainability in all its actions the manifestation of srm should be evaluated by a normative ethic of distributive justice and coordinated with a macromarketing disposition for constructive engagement when addressing the marketingsociety interface in this instance returning briefly to the language about definitional construction utilized in the endnote srm is the definiendumthe central concept in our explicationand cc so and ses are the core of the definiens comprising the definiendum the social contract as well as distributive justice and constructive engagement are the other explicated dimensions of the unabridged definiens we now address the context and composition for our proposed definition of srm context firstly because our delineation of srm is a normative construct that portrays a comprehensive ideal it has its own set of advantages because of its idealized form this definition of srm is more expansive than narrow ad hoc definitions of srm that might be formulated in empirical studies investigating finite research questions of socialethical marketing practices in these cases to reflect the research issue at focus srm is conceptualized more narrowly as in the amount of greenwashing or the extent of social auditing in the supply chain or by comparing advertised versus actual airfares statistical linkages are then explored with other variables furthermore because of the narrow marketing purview of some companies one would not logically expect all individual firms to address or reflect every element of the idealized srm definition we postulate however we would still assert and do argue below that all marketing firms are ethically bound by the full scope srm elements in the proposed definition second socially responsible marketing is part of the broader domain of corporate social responsibility in business thus there are issues and literatures that address not only csr in marketing but also csrhuman resources csroperations csrfinance etc much of what has been observed about csr in general is also applicable to marketing issues note too that academic research regarding social responsibility in business has been more popular in european circles than in the usa and elsewhere thus those exploring future csrmarketing questions should incorporate european journals into their search ambit third we would expect that positive definitions of business social responsibility found in the literature would be numerous and would vary considerably in their description why csr is a broad umbrella term it reflects collective social expectations for business and so the issuespecific emphasis of that expectation shifts over time and over topics for example environmental sustainability is a srm research focus of growing importance and current popularity given that climate change could overwhelm and devastate earths ecosystems some analysts plausibly argue that sustainability might be the overarching nomenclature for investigating and debating all socially responsible policy however with regard to the definition here postulated we assert our normative and macrolevel specification captures the full domain of srm concerns as explained below again since our definition is a macro ideal its scope and durability should be greater than issuespecific definitions used in most microempirical studies of srm or case studies describing csrmarketing campaigns to evaluate situational qualityoflife and societalterrestrial wellbeing composition two compositional observations about the fundamental nature and rigor of our srm explication are now put on the record we begin by referencing the process proposed by bishop about constructing normative formulations in moral philosophy bishop contends that specification of normativeethical concepts is far more complex than simple moral suasion instead every normative formulation ought to address certain essential parameters that provide justifications and restrictions to the core idea posed one might think of this procedure as similar to the statement of study limitations found in many empirical investigations concerning our proposed definition of srm we note in table 2 the requisite elements of theoretic ethical formulation as well as an abridged comment regarding its presence and conformity within our srm conceptualization normativeethical theory formulations table 2 elements of recommended values herein these values are the definiens elements of srm corporate citizenship stakeholder orientation and socialecological sustainability these complex valuesbased concepts are the essentials of socially responsible marketing broadly and normatively defined if a marketing organization claims to aspire to srm these values must at least be considered in their decisionmaking grounds for theory acceptance these consist of the commentaries below concerning each of the definiens elements in the definition of srm the worth of the definition is dependent on the quality of our conceptual explication decision principle for users primary here is the concept distributive justice which will be offered as a critical normativeethical standard for assessing the societal contribution of srm activities secondary are the various theoretical and ethical observations made about the elements of srm ie other ethical imperatives are still operative but dj is the guiding perspective tertiary here is the helping macromarketing perspective of constructive engagement ce can pragmatically aid marketers to focus on the potential beneficial outcomes from marketing activity 4 agents to whom the framework applies the definition is intended to inform analysts of the marketing system and all marketing practitioners supportive of srm interests to be considered all company stakeholders are at focus especially consumers with an eye to their economic and social wellbeing context of application all exchange transactions in the marketing system with primary emphasis on marketers operating in the forprofit sector are the central focus why is the forprofit sector of main concern many marketing organizations in the nonprofit sector or those engaged in social marketing already have social goals built into their mission statements it is the forprofit sector of marketing with its competitive climate and roi orientation that engenders the most controversy regarding socially responsible behaviors 7 legalpolitical structure being assumed the contemporary capitalistic system is our forum however as will be made clear the market system itself may be in flux and can be influenced and shaped by the amount and type of srm activity being practiced or institutional intervention besides adhering to the bishop process there is additional face validity to our approach in dissecting srm carroll perhaps the bestknown academic analyst of csr theory remarks that coming to grips with the social performance of business requires a clear definition an understanding of the issues for which social responsibility exists and a specification of the philosophy or pattern of responsiveness to the issues in our definition of srm the definiens elements express the categories of srm issues and distributive justice is the essential evaluative philosophy constructive engagement embodies the proposed pattern of responsiveness the social contract the seminal elementis the origin and foundation of srm thus we contend that our explicated comprehensive definition may be considered a descriptive doctrine of srm because a doctrine represents a set of beliefs about governing principles we propose that the explicated srm definition supplies the core concepts for describing and understanding a normative doctrine of socially responsible marketing the governing principlesthe beliefsbehind srm will become clearer below and hopefully will serve as a reference point when researchers conduct future empirical studies about srm what now follows is the formal and systematic explication process of essential srm terms reflecting on each element of the srm doctrine ought to yield a deeper understanding of the concept the social contract the genesis for socially responsible marketing at its root striving for marketing that is socially responsible and that improves the world raises the question of why such aspirations are desirable noteworthy or even required the answer to such inquiries lies directly in the concept of the social contract the social contract is the explanation and justification for caring about and engaging in srm the core of a social contract is that there exists an implicit but deducible understanding between collective members of society and business organizations including marketers this understanding involves the nature of what social obligations the public expects from businessmarketing practice and what benefits in turn are granted to corporations as eells and walton wrote in their classic conceptual foundations of business the large business corporation…is an indispensible instrument for getting done some of the things that people want done it is neither the exclusive instrument of one class of interests shareholders nor an indiscriminate roster of social interests… t he corporation has to be tempered to the times and as a viable instrument it must adapt to the changing requirements of our free complex and interdependent society many interested parties subsequently have asked where are these various societal adaptations and requirements for business written down where is the signed social contract to which other skeptics have sympathetically added the social contract isnt worth the paper that it isnt printed on this hypothetical q a evokes an important conclusion the social contract is not a blackletter document but rather a supralegal understanding that embodies implicit ethical obligations it flows from deducible societal expectations which businesses accept in exchange for their right to operate and seek profit without unnecessary regulatory restriction these dynamic expectations of society were long realized by business philosophers including the venerable peter drucker who remarked 50 years ago management will increasingly be concerned as much with the expression of basic beliefs and values as with the accomplishment of measurable results it business will increasingly stand for the qualityoflife of a society as much as for its standard of living marketing undoubtedly plays a tremendous economic role in provisioning the goods and services that all communities need to flourish and grow most of us accept indeed embrace the aggregate marketing system as a powerful economic engine for accomplishing societys provisioning goals the agms functions via markets with great and laudable distinction most of the time as wilkie and moore and numerous others have detailed marketers innovate bear risk provide critical information assembledisaggregate distribute transact and perform a host of other necessary functions that make possible a high standard of living in exchange the reward of profit fittingly accrues to successful and contributing marketing organizations but from a macro standpoint the unitary facilitation of successful exchange alone is not sufficient even if exchange is satisfying to both sellers and buyers certain market transactions can create ancillary problems for society such as social dysfunctions the depletion of critical resources or the generation of pollution these problems have collectively been referred to as negative externalities to protect against such broader negative outcomes the safeguards of societal interests come into play for example in the usa business firms receive a charter of operation from the state and in exchange the sanctity of their contracts as well as private property is protected by federal and state law in fact from its origin and according to the us constitution the us federal government always reserves the right to regulate commerce in the public interest thus the license to operate as a profitable provider of goods and services comes from society along with a set of presumed rights and duties one finds similar arrangements in most developed countries around the world to be balanced many marketing managers with oversight of firmlevel strategic units might respond to the above contentions by retorting i dont think i received the memo concerning the extraorganizational responsibilities of marketing micromarketers have understandably long believed that the market is best served when company operations are structured to cater to the customer in a satisfying and profitable manner at the firm level individual managers are mostly rewarded on unit level performanceroi sales growth and customer retention and consistent with classical economics micromarkets of consumerfocused mutuallyagreedto exchanges among sellers and buyers lead to benefits for the many such approaches typically provide a rational and efficient method for the allocation of resources plus it should be on the record that the guiding vision for many marketing professionals is customer orientation marketing organizations tout their customerattentive marketing by using research based algorithms to make operational decisions about products prices distribution and the like a major theme that pervades the marketing literature is the ambition to be customercentric this view is embodied in core marketing ideas such as the marketing concept relationship marketing and even cocreation with customers the clear thematic is that satisfied customers are the primary focus of marketing activity and serving them well is the ultimate service to society but it is here once again that the macro perspective comes into play by adding a less dyadic less instrumental outlook at this broader level a systems perspective appends another stratum of concerns to the societal goals of marketing activity indeed a historical analysis of marketer conceptions of the consumer suggests that genuine customer orientation has been but a limited fragment of marketings legacy marketing as a discipline had its roots in early 20th century institutional economics the phd students of these early economists established the first academic departments of marketing in this primal stage the original marketing scholars concentrated on understanding aggregate retail transactions and the distribution of agricultural products and from the outset early writers emphasized marketings economic role its broader than technical management role and its social responsibility john maurice clark one of those early institutional economists sagely warned of the dangers of too great a firmlevel focus in guiding economic decisions clark wrote we have inherited an economics of irresponsibility…we need an economics of responsibility developed and embodied in our working business ethics for clark all of economics needed to be understood from the lens of society because every market decision had a societal ramification howard bowen thought by many to be the father of corporate social responsibility echoes a similar theme when he originally defined social responsibility as the obligations of businessmen to pursue those policies to make those decisions or to follow those lines of action which are desirable in terms of the objectives and values of society such foundational perspectives suggest that srm is anchored in a moral imperativea social contractthat flows from society itself but what are the terms of this contract if its details are implied what can we know of it business ethicist donaldson in corporations morality provides an enlightening and multifaceted picture of the social contract donaldson posits that profit seeking organizations receive recognition in the eyes of the law along with the right to use and own capital resourcesland employees and moneyfor their individual and comparative advantage in exchange citizens expect to have certain economics interests satisfied in an efficient and effective manner this includes their wellbeing via access to neededdesired goods and services employment opportunities and the protection from unwanted sideeffects for themselves and their communities the social contract gives companies the right to create and retain capital but in exchange for a mandate to shield consumers workers and other stakeholders from substantial harms this tradeoff between business and society is effectively an ethical partnership of duties exchanged that imparts to business and its marketing agents assorted social obligations in exchange for their established rights the precise nature of the ethical obligations flowing from the social contract will be further addressed when the definiens element of distributive justice is discussed later but for the moment we encourage readers to consider the words of kenneth arrow nobel laureate in economics who eloquently wrote about these unseen workings of the economic system there is another set of institutions if that is the right word we call to attention and make much of these are invisible institutions the principles of ethics and morality certainly one way of looking at ethics and morality a way that is compatible with this attempt at rational analysis is that these principles are agreements conscious or in many cases unconscious to supply mutual benefits…the fact that we cannot mediate all of our responsibilities to others through prices though paying for them makes it essential in the running of society that we have what might be called conscience a feeling of responsibility for the effect of ones actions on others what are the takeaways for marketers from this discussion of the social contract 1 the sc is the underlying rationale that supports the importance of engaging in socially responsible marketing it is the apparatus that supplies the transactional logic behind srm while also providing a coherent motivation for engaging in it 2 the social contract is implied but its cultural effects are very real its deducible implications result in rights for marketing organizations along with responsibilities to marketings stakeholders 3 while faithfully serving customers is part of marketings social contract the social obligations of marketers are far more expansive than only economic functions 4 the general imperatives of the sc only some of which are embodied in the law involve taking actions that protect and improve the collective of society such actions are the requisites of srm and as indicated below the specifics of the sc are more fully captured in the elements of corporate citizenship stakeholder orientation and socialecological sustainability the core elements of srm a preamble as ventured in our definition from a macro and normativeethical standpoint socially responsible marketing is the summation of corporate citizenship stakeholder orientation and socialecological sustainability or put symbolically srmfn again the definition is normative because it specifies the domain of what srm ought to ideally include it is macro because the requirements concerning societal expectations for marketing can be best discerned from a systems standpoint rather than induced from the micro scrutiny of individual firms preoccupied mainly with their financial targets and only secondarily with social impacts in the sections below cc so and ses will be more fully described especially in their marketing manifestations but it is important to recognize that each of these terms at various times in the academic literature has been individually defined as being equal to corporate social responsibility including in its marketing dimensions that is it has been argued at some point that srm cc by marketers or srm so or srm ses to briefly illustrate that point business ethicist waddock conceives of corporate citizenship as encompassing all of csr although she readily admits that many scholars might disagree freeman first articulated stakeholder theory as the systematic network of business relationships that sheds light on how business ought to be managed for the benefit of interconnected parties building on freeman the network of stakeholder claims has been an oftenused method to fully structure and oversee the implementation of csr in organizations including marketing issues and in recent years sustainability has been portrayed as totally encompassing csr because all commercial activity can be imagined as positively or negatively impacting human and ecological systems the presence of all these terms in our delineation of srm adds scope and richness to our definitiontwo attributes deemed desirable to useful marketing theories we do not advocate that any one element of our definition is supreme or most important rather depending upon the situation at focus one or more of the srm components may temporarily become more prominent also of interest here is a content analysis of assorted codes of business conduct codes of conduct are typically idealized values statements that outline the legal moral social or cultural expectations according to some organizational group one can look at such corporate codes as an embodiment of what particular firms understand the social contract to be in 2011 laczniak and kennedy reviewed seven such prominent codes principles of business behavior the un global compact but what was novel here was that each of the codes investigated was formulated by a different constituencygovernment regulators business executives academics environmental advocates etc the expectation was that each formulating group would skew their concerns to their own interestsie environmentalists would focus on ecological issues bureaucrats on regulation managers on deregulated markets and so forth to an extent this supposition was borne out but more tellingly all of the different codes included three common hyper norms stakeholder orientation sustainability and authentic compliance compilations of societal and ethical expectations for business conduct ought to reflect the dimensions of srm defined and in consonance the referenced survey so finds we now explicate corporate citizenship the first element of normative srm corporate citizenship it is hard to imagine a socially responsible marketing firm that would not embrace good corporate citizenship us law as well that of other countries attributes personhood to corporations thus the expectation of good citizenship by companies is hardly an illogical stretch while corporate personhood itself might be an artificial construct this conception has vast pragmatic significance because corporations persist over time can enter into contracts and since they control assets affecting economic wellbeing can be held financially liable when appropriate plus because organizations also exhibit intentionality for their actions via their written policies they can be construed as having moral agency as famously argued by french also owing to their importance as economic actors the notion of good corporate citizenship as vital to srm is not only sensible but indispensable votaw in a seminal article reasoned that corporations must be viewed as significant political actors given their substantial size influence and power possessing such economic authority these citizencorporations should anticipate being called on to play a positive social role thus consistent with the discussion of the social contract already highlighted rights and responsibilities appear to be obligatory to the corporate license of personhood that is because corporations have rights as citizens do and they would be expected to demonstrate their imputed responsibilities just as citizens are called on to defend their country participate as jurors in the legal system and vote while friedman in a narrow construction of social responsibilityto maximize company profitsdid not specifically invoke citizenship even his notion was not inconsistent his approach was simply an attenuated and misinformed consideration of citizenship according to friedman corporations should obey the law but corporations like some less civicminded less caring citizens should not be forced to sustain ancillary social outreach this is a view that has been increasingly rejected since the 1970s owing to the growing public expectation that as powerful players in the social fabric good citizenship from corporations is demanded some of these manifest expectations have been enshrined in law many are ethical imperatives and others are discretionary but always it seems some level of demonstrated proactive social engagement by most corporations is supposed moreover the public inherently understands not all business firms have the same level of responsibility people recognize that smaller startup businesses struggling for survival may not be predominantly concerned about societyenriching actions even as they still must honor the basic social contract for larger robust organizations the ethical mandate of good citizen contributions beyond the law is very real as far back as 1960 keith davis another csr theory pioneer proposed his now famous iron law of social responsibility daviss law was neither enshrined in the regulatory code nor an inviolate scientific principle but as a general tendency it neatly reflected societal expectations about corporate citizenship the iron law stated company social responsibility needed to be proportionate with company social power thus for the most part large corporations were expected to exhibit greater social responsibility than smaller firms in a marketing context firms such as walmart starbucks facebook and alphabet would have high expectations thrust upon them furthermore according to davis frederick and blomstrom a corollary to the iron law also could be discerned from history if an organization did not use its power appropriately its influence would eventually be reduced or constrained by society in some fashion some skeptics in the marketing discipline still remain regarding corporate citizenship needing to exceed the law they typically parrot friedman and contend the only srm required is to conduct marketing and conform to the extant law however the vast majority of marketing vps and cmos now rebuke such thinking in part because it has been so effectively debunked by logical refutation and public opinion polls it would be a rare cmo who would relish publicly professing the only social responsibility of my marketing campaigns is to maximize shareholder gains thats it even adam smith the grandfather of unfettered markets in his other book the theory of moral sentiments which he continued to revise until his death recognizes and encourages the altruistic tendencies of human nature consider these two passages how selfish so ever man may be supposed there are evidently some principles in his nature which interest him in the fortune of others and render their happiness necessary to him though he derives nothing from it except the pleasure of seeing it… and man ought to regard himself not as something separated and detached but as a citizen of the world a member of the vast commonwealth of nature and the interest of this great community he ought at all times to be willing that his own little interest should be sacrificed we suspect only a minority of marketing academics and fewer practitioners are familiar with this decidedly ethical dimension of the iconic adam smith but that the broad acceptance of proactive corporate citizenship is emergent also can be illustrated by the number of company signatories to the un global compact a set of 10 ethical principles that corporations operating in global markets agree to abide by the principles first postulated in 2000 are divided into the categories of human rights labor standards and environmental protection as of 2016 more than 8000 corporations with international operations have made a nonbinding commitment to support and abide by the principles these principles each accompanied by a page or more of commentary have clear implications for marketing practice such as prohibiting child slave or exploitative labor in the supply chain and renouncing bribery in all foreign markets the growth in subscription to these principles while voluntary is further evidence of the strength and importance of good corporate citizenship to srm to a great extent marketing academics have willingly embraced being good corporate citizens when their strategies can blend doing good with doing well financially the utilization of causerelated marketing by many organizations is just one case in point to this end marketing academics have conducted notable research to help guide organizations in their selection of efficient philanthropic and volunteer initiatives that may also elevate the bottom line however it is more challenging for individual marketing firms to exercise the highest level of corporate citizenship when taking the higher road of srm might reduce their financial rewards much of the time the profit impact on srm on firmspecific objectives is cloudy a point further discussed later this again evokes the question of why marketers and their organizations should embrace duties beyond those that might directly aid the bottom line for example marketing executives intuitively understand that volunteerism may smooth public relations in a host community where cooperation is important they perceive the value of providing job training programs when replacement employees might be in tight supply they realize that visible philanthropy may be connected to the brand equity of company products but what about practicing of corporate citizenship for its own sakebecause cc is the right thing to do taking a normative and macro perspective provides a plausible answer philosopher and economic policy analyst michael novak put forward the idea that management is a vocation or calling encompassing a societal responsibility not only to oversee company resource allocation but to also give back to society in a way that is community affirming in this vein marketing management also can be seen as a vocation a noble vocation to provision society and to do so in manner that adds not only economic value but also enhances the common good by making the world better viewing the practice of marketing as a calling that embodies srm would be a clear demonstration of corporate citizenship as an ethicallyinspired ideal ideals aside for a moment hundreds of descriptive studies of marketers ethical behavior at the firmlevel have been reported some identify factors that seem to impel greater srm and others paint situations that detract from ethical actions marketing academics have also constructed detailed models of the ethical decisionmaking process that frame such empirical studies these last two works are among the most cited in the marketing discipline however these models do not address how socially responsible marketing decisions should be made nor do they specify how macrosocietal variables inevitably affect decisionmaking until the academic marketing community agrees on the critical macro factors and a guiding ethical code of essential srm debate will continue about the implications of empirical findings regarding marketings social accountability and what policy modifications they imply given the discussion of corporate personhood the link of corporate power to responsibility and the nondiscretionary obligation of business to the commonweal we submit that good corporate citizenship is the first requisite of socially responsible marketing and a compulsory element of srm so to sum up what have we concluded from this exposition of corporate citizenship 1 corporations similar to citizens have rights and responsibilities these include the requirement to follow the law the obligation to act ethically in a variety of ways and the discretion to undertake philanthropy and voluntarism that benefits the community and perhaps their brand reputation 2 the responsibility to fulfill cc is commensurate with corporate power repeated failures to engage in responsible marketing will result in legal sanctions additional regulation constraints upon offending the industry or other reductions in market power 3 adherence to high ethical standards is a professional requirement for marketers the american marketing association statement on ethics make apparent that specific ethical obligations exist which all marketers are expected to embrace the notion that srm in its fullness is legally codified andor discretionary is simply not tenable in todays media transparent marketplace public expectations about the need for improved business and marketing behaviors are evident in media and press reports nearly every day 4 the practice of marketing when viewed normatively and from a macro standpoint might be conceived as a callinga professional vocation that seeks pathways to achieve marketing goals while integrating societal contribution into a firms activities understanding marketing as a vocation that impacts society internalizes the commitment of company managers to good cc and socially responsible marketing we now explicate stakeholder orientation the second essential element of srm stakeholder orientation recognizing a stakeholder orientation with an authentic consideration of stakeholder claims is perhaps the element most often evoked as essential to csr and by extension to socially responsible marketing because stakeholders represent the collective of societal parties impacted by marketing actions it can be difficult to grasp how marketing is or is not acting responsibly without analyzing stakeholders and what might be owed to them one of the ways that so is different from corporate citizenship is it shifts the spotlight to the impact of marketing on various parties rather than addressing the imputed responsibilities of marketers ferrell ferrell and sawayda in their excellent review of csrmarketing literature opine in trying to develop a framework for corporate responsibility in marketing the stakeholder framework seems to have the most support in actual practice often leaning on customer relationship marketing as well as the marketing concept marketing managers employ contracts public relations lobbying placation channel power or litigation to smooth communication and negotiation with their various stakeholders all with an eye to improving customer perceptions brand equity and of course profit thus we dig deeper into the concept of stakeholder orientation and what it adds to srm stakeholder is a fairly old term historically referring to any party with a stake in a financial transaction it dates back to at least 18th century juris prudence but stakeholder theory first came to the fore in business parlance with the publication of freemans now classic strategic management a stakeholder approach a stakeholder was any group or individual who can affect or is affected by the achievement of an organizations objectives the central thesis of freemans seminal work was that companies that could effectively manage their stakeholders will perform better than those which were not as adept obviously from a marketing theory standpoint one always primary stakeholder to be satisfied is the customer although other important partiessuppliers distributors and employeeswould also be critical to organizational success ownershareholders are also primary the status of a primary stakeholder means exactly that their claims and considerations normally have priorities over lesser stakeholders the essence of a stakeholder approach for an individual firm involves creating a strategic plan that manages the rights and claims of various stakeholders in a manner consistent with the organizational objectives since different stakeholder groups desire different outcomesie owners want roi customers want safeinnovative products and services employees want good paying jobs etcstakeholder oversight is a difficult balancing act reflecting the apex of managerial complexity over the years even freeman the progenitor of stakeholder theory has been conflicted over how much economic advantage should be sacrificed to honor all significant stakeholder claims skeptics of stakeholder theory point out the difficulty of determining who the most important stakeholders are other than ownersshareholders marketers normally elevate the customerstakeholder to a primary level because of the strategic value of customer satisfaction but what about franchisees distributors suppliers are they primary or secondary such designations require careful discernment but this is not an intractable problem mitchell agle and wood in a now famous article enumerated the criteria for sorting stakeholders into a primary or secondary status these criteria are power legitimacy and urgency while mitchell et al is not the only possible approach to such delineation using analytical case studies marketing academics have illustrated the utility of the mitchell agle and wood approach for both classifying stakeholders and assessing the import of stakeholder theory to marketing strategy stakeholders that possess one or more of these three characteristics are owed thoughtful consideration hence authentic stakeholder orientation the level of aggregation at which one examines soie a micro versus macro lensis an even more important factor from the standpoint of the individual firm adopting a mostly instrumental and financially focused perspective of stakeholders makes sense freeman originally conceived the stakeholder network as a hub and spoke model with the firm at the hub coordinating or coopting various accommodations to stakeholders arrayed along the figurative rim marketers have often embraced this microinstrumental perspective with varying rationales and persuasiveness typically stakeholders are seen as entities to be dealt with like any other factor that impinges upon competitive advantage but an important and sometimes forgotten codicil is that stakeholders have both a strategic value and a moral claim upon the organization jones proposes that it is the moral claim of stakeholders that makes stakeholder theory noteworthy from a csr perspective that is authentic stakeholder orientation requires a type of socially responsible behavior that considers what duties are fairly or justly owed to articulated stakeholders from solely a microstrategy standpoint stakeholders well managed improve the efficiency of the firm academic marketing researchers have regularly sought to identify the important levers of such efficiencies we encourage readers to consider a few sample illustrations smith and coopermartin utilizing the empirical support of public opinion surveys show that certain types of target marketing especially for controversial products can result in marketing strategy failure antia and frazier analyzing over 200 franchisors finds that network density lessens enforcement of contractual obligations in the distribution channel mish and scammon in studying firms that have moved from private to public ownership conclude that stakeholder orientation is harder to maintain once the publiclytraded transition has been made martin and johnson using a gamecentric experimental design find managerparticipants to be willing to promotionally leverage positive treatment of supplychain stakeholders even when such information cannot be verified these investigations improve stakeholder understanding for marketers and none of them excludes the possibility of making adjustments such that the economic objectives of the firm and the wellbeing of stakeholders are both satisfied simultaneously however the subtheme of many stakeholder studies reveals that financial objectives for shareholders are to be maximized while ethical obligations to other stakeholders are to be merely satisfied for example when thinking about stakeholders only instrumentally marketers may conclude customerstakeholders should be treated well because retaining customers is less expensive than attracting new ones product safety should be emphasized due to experiences showing that torts litigation by consumers is expensive the ecological environment should be protected in order to forestall additional regulations or consumer boycotts such conclusions while valid are rooted mainly in competitive advantage taking a macro and normativeethical perspective to stakeholders markedly changes the thinking and dynamics described above again the social contract what business owes to society for its rights of operationunderscores the societal purpose of marketing from the standpoint of the public interest authentic stakeholder orientation extends beyond customer satisfaction and maximal profitability for shareholders it ought to include ethical as well as strategic considerations its macro view considers the full network of stakeholder relationships not solely the sellerbuyer dyad the previously cited authors call this hardform stakeholder orientation because it overcomes the problem of embracing stakeholder theory merely for its instrumental value that is firms utilizing stakeholder theory mostly from the perspective of customer fulfillment or shareholder profit may ignore the common good for example buyers and sellers of ecigarettes both may be satisfied but still create health costs for society armaments manufacturers that produce antipersonnel mines may enhance military operations but contribute to the unintended loss of civilian lives energy companies that use fracking may lower fuel costs to consumers by increasing supply but add to unforeseen environmental damage to better untangle such problematics for society various business ethicists have advocated taking a macro approach to stakeholder relationships that deemphasizes the sellerbuyer dyad and instead looks at the macro network of stakeholder connections to better see the full spectrum of societal impacts from market transactions bhattacharya and korschun were among the earlier marketing academics to recognize that socially responsible stakeholder theory needed to be not only financially conceived but more enlightened by reflecting prosocial and proenvironmental considerations such srm thinking channeled the thenemergent triplebottomline formulation of people and planet plus profit bhattacharya in that spirit writes …recent realities such as climate change obesity crises and human rights violations…are prompting companies to look beyond customers as the sole target of marketing activities and firms as the primary beneficiary… t here is an urgent need for new research that adopts a broader and more inclusive stakeholder orientation ferrell et al agree but point out the typical firm is focused on customers competitive advantage which they label market orientation that approach is likely at odds with what the public increasingly expects from stakeholder orientation in addition they go on to speculate that aligning the two orientations may be quite difficult with mo often trumping so to be pondered here are not only the questions regarding who the various stakeholders are and what primary claims are to be addressed but also by which rules and ethical standards those stakeholder claims are to be adjudicated this fundamental and necessary question of how to analyze not only the legitimacy of stakeholder claims but other contingencies affecting stakeholder oriented srm will be addressed in our explication of distributive justice finally it is imperative to note that in august of 2019 the business roundtable an association of many dozens of ceos from large multinational companies signed a statement amending their views on the purpose of a corporation they emphasized that the purpose of companies involves a fundamental commitment to all our stakeholders this supersedes the view of brt that the primary purpose of the corporation is to protect and accumulate shareholder wealth interestingly between 1981 and 1997 the brt held a more stakeholder centric view of company purpose to which they have now returned is the brt stakeholder pledge too broad and aspirational to really hold managers accountable some parties contend shareholders and perhaps society itself are not well served if corporations or their marketing units become too enamored with stakeholderism difficult stakeholder tradeoffs may inevitably force some managersexecutives to choose shareholders over employees or the environment if only temporarily that is sometimes a limb must be painfully sutured or amputated to save the patient however responsible authentic soan aspirationrequires that such tradeoff discussions be transparent and that all stakeholders would have access to the decisionmaking process and its outcomes these matters are further discussed in the sections on distributive justice and constructive engagement for the present what has been distilled from our examination of stakeholder orientation 1 the adoption of a stakeholder orientation appears to be essential to advancement of socially responsible marketing because stakeholders are the identified claimants in society owed authentic consideration by marketers 2 while identifying and ranking stakeholder claims has often been posed as exceedingly difficult enlightened marketers have demonstrated a variety of ways in which that can be done 3 managing stakeholder relationships from only a firms position of selfinterest is contrary to many of the prosocial proenvironmental tenets of hardform stakeholder theory including the stated opinion of influential groups such as the ceos of the business round table 4 the network of stakeholder relationships that constitute srm is better visualized with a macrosystems perspective rather than from a microfirms sellercustomer dyad customer satisfaction while always important does not take into account the full scope of negative externalities of market exchange that a systems perspective uncovers we next explicate the element of socialecological sustainability the third essential piece of socially responsible marketing social and ecological sustainability srm always aspires to achieve socialenvironmental sustainability as part of its provisioning and exchange functions the concept of sustainability is complex and while marketings expected contribution to this effort is finite it is nonetheless imperative and collectively significant saiia describes sustainability as the integrated understanding of the interconnection of human activity upon manmade and natural systems as benton has pointed out there are numerous interpretations of sustainability but a common denominator of all of them involves thinking holistically about economic ethical and environmental interactions the understandable supposition in ses is that the longterm wellbeing of society and the health of the physical environment are inextricably connected thus social and ecological sustainability marketing comes into play because it is the central system of resource allocationdistribution for meeting consumercitizen needs collectively marketing discharges that duty pretty well that noted marketing organizations are often implicated in driving overconsumption and wasteful resource usage that is marketing is sometimes viewed as an obstacle to or enemy of sustainability on the flip side as a transformative institution ecologically mindful marketing can make an enormous contribution to a healthier planet as well as to value creation ses is the piece of socially responsible marketing that is concerned with marketings impact on the physical environment obviously an ethic of sustainability in marketing operations can create economic social and ecological differences points we outline below the term sustainability as a global public policy objective was introduced by the united nations brundtland commission on environment and development that report sought to lay out a pathway for further world economic development without compromising the resource inheritance for future generations sustainability is part of environmental ethics and economics which itself is often historically linked back to rachel carsons iconic silent spring and her early warnings about the impact of human interventions upon environmental systems other scholars trace environmental ethics back to early 20th century naturalists or even the ancient greeks but the main point here is normative a sustainability approach is proposed to be a key solution to the depletion and degradation of earths resources and thus a necessary piece in comprehending marketings role in society ie its social responsibility to this end in 2015 the united nations approved 17 sustainable development goals for 2030 these goals each with many pragmatic subpoints laidout a comprehensive blueprint to assure the future prosperity of the planet the allinclusive themes of 17 sdgs include aspirations such as end poverty decent work and economic growth and climate protection action the most marketing focused sdg 12 responsible consumption and productionwill be addressed below for years creating sustainable economies has been considered an existential challenge recently even pope francis authored an encyclical laudato si calling for greater stewardship over our common homemother earth one of the most quoted sentences of that document at 21 reads the earth our home is beginning to look more and more like an immense pile of filth in amelioration francis invokes the principle of stewardship as an ethical guide for environmental decisions in its most general form the principle of stewardship calls on economic actors to always respect the integrity and cycles of nature and to fastidiously avoid environmental exploitation particularly significant about laudato si is that it represents a major shift in moral perspective by religious institutions not limited to the roman catholic church western religious doctrinestill a substantial cultural and global influence increasingly views the world as less anthropomorphic and has tempered its historic view that the planet is a bottomless resourcebank exclusively intended for human benefit also in 2015 mirroring the concurrent efforts of the un political elites from around the world gathered in paris to negotiate a climate change mitigation treaty intended to alleviate predicted lifedamaging effects if environmental practices remained unchanged in 2018 us president donald trump withdrew the usa from the paris climate accord causing great domestic and international angst such events show that the enormous marketing system itself is subject to and enmeshed in the machinations of other macro systems many factors influence the extent to which the aggregate marketing system can affect the physical environment but clearly the activities of marketing are central marketing decisions impact the materials that are extracted from the earth the level of substances that can be reabsorbed by the planet degradation of the physical biosphere and the ecological footprint of various populations from its beginnings environmental policies and oversights were something that needed to be analyzed at the macro level but fixed at the micro level while the scope of such systemic analyses can seem overwhelming to reduce complexity business ethicists such as gibson suggest managers focus on controllable sustainability within their individual enterprises while still recognizing macro trends thus the policy choices individual marketing firms make are vital un sustainable development goal 12 is principally centered on marketing concerns sdg 12 seeks to ensure sustainable consumption and production patterns by committing all organizations to environhelpful marketing practices including bioefficient packaging greater recycling and reuse combating product obsolescence plus a half dozen other strategies sustainable thinking about economic exchange has included marketing themes going back to the 70s as environmentalism exploded in the public consciousness academic marketing scholarship was quick on the uptake consistent with our discussion of the social contract marketers realized that ecologically benign marketing was an ethical imperative or an attractive profit opportunity or both the term green marketing was eventually coined and referred to assorted activities by which customer needs could be satisfied with minimal detrimental impacts on the physical environment green washing in contrast to green marketing involved exploitative ecological marketing where false or misleading product claims were made purporting sustainable attributes that were not real many helpful academic investigations into various aspects of sustainable marketing continue to the present including several appearing in the journal of marketing and elsewhere marketings general recognition of the srm significance of social and ecological sustainability seems established years ago zaltman kotler and kaufman in discussing the process of social dynamics noted three approaches that impel major social change such as the adoption of an ses philosophy these were coercive power utilitarian evaluations and normative ideals marketers driven by profit payoffs have typically been motivated by strategy and sometimes in their efforts to become more sustainable but one lesson evident in our abridged review of sustainability is that genuine srm also requires being more open to the normative approach benton scrutinizing the environmental impact of marketing on society remarks that instead of marketers asking can it be sold they ought to first inquire should it be sold is it worth the environmental cost to society once such alternative questions are deemed important it is a short step to realizing that genuine srm includes socialecological sustainability a quintessential macro and ethical concept what are the key takeaways from our brief tour of the ses perspective 1 because marketing is embedded in a greater macro ecosystem thinking holistically about environmental impacts is essential to the concept of socialecological sustainability and its srm interface 2 the public increasingly comprehends the possible influences of marketing activities on the physical world and its societal wellbeing thus ses is an expected piece of socially responsible marketing 3 the principle of stewardship calls on economic actors to always respect the integrity and cycles of nature and to fastidiously avoid environmental exploitation marketers are called on to discern what that means for their practices 4 un sustainable development goal 12responsible production and consumptionis one notable starting point for a global ethic of ses in marketing 5 thinking normatively with a macrofocus can help marketing managers recognize srm practices that are both ecologically friendly and profitable having completed our explication of the basic elements of srm we now address a prospective ethical standard of assessmentdistributive justice because dj is a particularly intricate topic this discussion is organized with five fundamental questions why is distributive justice an indispensable ethical standard for srm what is the nature of distributive justice what is the proper measure of distributive justice is there a surrogate indicator for dj to be found in market outcomes what happens to market systems without sufficient distributive justice distributive justice an ethical standard to evaluate srm why is distributive justice an indispensable ethical standard for srm there are assorted ethical frameworks that can be used to analyze socialethical questions that present themselves in marketing practice for instance the hunt and vitell model of marketing ethics is constructed on the idea that marketing decisionmakers depending on the situation likely opt for either teleological or deontological frameworks of ethical analysis distributive justice which focuses on trying to shape fair outcomes for all is an ethical standard that is particularly suited to evaluating macro or systemslevel issues for example in the current covid19 pandemic the thorny tradeoff between protecting public health via social quarantines and its detrimental sideeffects of constricting the economy and employment opportunities has been debated rigorously in terms of the distributive justice of social outcomes these discussions have been less than definitive fortunately most of the time when it comes to evaluating less novel ethical questions like the use of extortion blackmail and pricefixing to advance business interests most ethical frameworks including dj are in consensus about what is fair and proper regarding the nature of socially responsible marketing it has been argued that distribution justice particularly as conceived by rawls holds considerable potential in helping understand the fairness of markets and marketing practices in a marketing systems context dj deals with how rewards and penalties are apportioned among the various parties affected by the market exchange process a distributive justice approach is especially useful at the macro level because the rawlsian form of dj includes an inherent public policy component dj presumes social institutions will make adjustments in the market system to increase fairness among all parties to achieve this the rawlsian approach to dj features an ethical principle that gives special consideration to vulnerable groups when new social policies are considered selecting dj as the ethical standard as essential to srm does not dispense marketers from following other ethical dicta instead it is a primary ethical standard for srm because it most easily allows analysts of macro systems to parse what is going on in terms of fair societal outcomes what is the nature of distributive justice just as the social contract is the foundation of socially responsible marketing distributive justice is its moral measure thus if the social contract is being rightly executed distributions in a given market sector will be considered just hence the question of what marketers justly owe society is by logical deduction a macrolevel inquiry in other words in trying to establish if society and its stakeholders are being fairly treated by particular market arrangements one must undertake ethical examinations that are macro and systemic because only such measures are able to capture broad societal expectations monieson advocated that macro perspective when he asserted distributive justice is a central concept in macromarketing the subject of distributive justice embraces not only the economic analyses of rights but also ethics morality religion and even aesthetics…any macromarketing ie marketing and society issue worthy of attention will ultimately have to confront these philosophically laden subjects they simply cannot be avoided ferrell and ferrell drawing on a wide swath of marketing and management literature postulate distributive justice as a vital framework to assess what marketers owe to assorted stakeholders including customers and society to fully understand the immense significance of dj for scrutinizing srm some universal comments about types of justice and their connection to the marketing system are helpful justice is important to marketing practice in all its forms but distributive justice is especially significant when looking at srm from a societal perspective as we further elaborate below most marketers probably consider the idea of justice to be a bit different from its distributivejustice variant general justice justice in its most familiar formis an ancient concept it addresses good values that fairminded individuals are asked to exercise in order to contribute to the common good to act justly is a universal ethical imperative captured among other places in the first lines of the biblical book of wisdom choose justice you who govern the earth the most typical embodiment of gj is the obligation to treat similar situations similarly an obvious example of gj in marketing practice is the duty to avoid price discrimination since it prima facie treats different buyers differently yet it is commutative justice that most marketers likely imagine when marketplace fairness is at question cj requires equality and reciprocity in exchanges among individuals or small groups and it is an important facet of understanding ethical marketing transactions but the main focus of cj is upon directparty exchangethe buyerseller deals so vital to the marketing function klein remarks that product merchantabilitysafety and fitness of products for purposes claimedis the most prominent form of commutative justice in marketing santos and laczniak echoing longstanding consumer rights theory remind of access to relevant information meaningful choice options freedom from exchangecoercion and redress from negative outcomes for their list of cj fair exchange with consumers however distributive justice is broader than cj because it goes beyond direct market exchange and extends to all stakeholders affected by marketing practice laczniak and murphy describe dj as the process by which an organization allocates to its stakeholders the benefits and burdens of economic enterprise according to some ethical standard of fairness it could be rightly deduced that in a marketing context dj is a subset of general justice and more encompassing than commutative justice obviously justice is a multidimensional concept but from the standpoint of srm distributive justice best captures the claims of society on marketing enterprises why because dj involves parsing how the rewards and costs of commercial activity should be fairlyie justlyallocated to all stakeholders not merely customers attention to dj begins to answer the questions is marketing practice x fair is marketing action x good for society what is the proper measure of distributive justice upon what basis should such dj assessments be made herein we find the devilry of detail the standards of distributive justice can be diverse and complex rewards to marketingaffected parties might be antecedently apportioned based on effort expended amount invested merits of ones contribution or by prenegotiated contract or post hoc distributions could be made on the basis of need or to achieve outcome equality or to be consistent with some other socially desirous rule thus there exist sundry standards of distributive justice and they may apportion outcomes differently so where does one even find the allocation algorithms and evaluation schemes for dj in marketing while such processes are admittedly difficult the literature includes several recommendations for applying dj to marketing issues and questions one of the most typical approaches is to identify primary stakeholders and then apply a costbenefit approach to the situational outcomes of parties affected by the marketing transaction at focus as costbenefit analysis is a staple of most mba programs the application of such thinking to dj should not be a great leap for marketing managers detailed attempts to compute the social performance of business have existed longer than many academics likely surmise at minimum many such measures involve auditing actual business practices to determine what steps companies have taken to honestly address assorted social issues the perennial marketing audit to help establish strategic positioning has also been adapted to ascertain an organizations ethical orientation in their marketing activities the extension of such audits to illuminate the srm components of corporate citizenship stakeholder orientation and socialecological sustainability can serve as commonsense building blocks to appraise dj of course the construction of such srm measurements still requires making choices about the precise nature of distributive justice measures for a defensible dj standard laczniak and murphy advocate building on rawls theory of justice this involves the general justice requirement of equal access to offices and opportunities but also incorporates a further ethical condition that directly reflects dj in marketing this translates to implementing the authentic stakeholder orientation discussed above but also added is the rawlsian difference principle for assessing outcome fairness to marketings stakeholders this supplementation means checking that marketing policies will not further disadvantage those in society who are least well offthe poor minorities the marketplace illiterate and other vulnerable segments further building on rawls but more expansively economist and nobel laureate amartya sen invokes a lofty dj standard with the concept of capabilities according to sens capabilities theory all persons should have access to the social goods and services that give human beings the ability to live a full life and achieve their potentiality philosopher martha nussbaum clarifies this idea by articulating exactly what these capabilities might beeg access to healthcare educational opportunities adequate resources to allow personal improvement to be sure all of these capabilities would not be provided by marketing activities alone sen and nussbaum are speaking to what comprehensive distributive justice should look like in a good society but a key dj implication for marketers is touched on along the way both sen and nussbaum note that genuine citizen wellbeing must always be judged not by the material output of consumer culture but rather by the extent to which individuals have access to the capabilities that will allow them to flourish as healthy happy human beings one clear implication here is that the true measure of marketing success according to dj is much more than financial perhaps the most detailed treatment for analyzing dj in commercial settings can be found in donaldson and dunfee whose approach was tailored for marketing situations by dunfee smith and ross this protocollabeled integrative social contracts theoryis complex and requires a discussion forum for key stakeholders such that they have sufficient voice to negotiate a set of ground rules andor principles to which all would agree in the abstract this consensusdirected approach appears exceedingly difficult but for many small and medium size companies the major social fairness questions they face are often limited such as pipeliners assuring the ecological integrity of their projects or hr staffing firms avoiding employee discrimination notably detailed guidelines for comprehending stakeholder claims have been formulated and over time will likely be further refined even multinational corporations after consultation with stakeholders can be transparent about what society should expect from their operations on occasion especially in unstable developing markets mncs themselves assume some socialsupportive roles in lieu of government actions nonetheless promises to stakeholders by marketing firms do not always or necessarily translate to srm action is there a surrogate indicator for dj to be found in market outcomes since dj is about realized outcomes one productive approach has been to explore how various marketing practices and arrangements have affected quality of life sirgy has offered complete views of qol investigations documenting how such outcomes include not only a systems economic results but citizen health leisure options work opportunities religious tolerance political freedom and family time not surprisingly the relationship between marketsmarketing practices and qol is a staple of macromarketing scholarship a specific example of distributive justice research in macromarketing is to examine how economic systems in different countries affect qol similarly macromarketers often study how alternative market constructions influence qol the overall point here is not to instruct concerning the tactical details of applying a particular dj template to marketing outcomes but to indicate that it can be done the exact process may need to be customized to the firm or industry at focus and that some distributive justice standardbecause of its focus on societal rewardcost allocationshelps capture the essentials of whether particular marketing arrangements are perceived as fair by stakeholders and society all of this suggests that unless some distributive justice calculations are made it is difficult to claim that srm is being delivered in a market subsystem what happens to market systems without sufficient distributive justice sporadic failures by business and marketing to assure distributive justice can have catastrophic social consequences the great recession was a case point as big banks which recklessly overextended consumer credit were bailed out by the us government while millions of americans lost their homes the end result from unfair distributions of market outcomes is this enduring public perceptions of unmerited inequalities of outcome that will cause citizenconsumers to question capitalism and the basic workings of the market system eminent historians will and ariel durant who spent much of their lifetimes producing a massive 10 volume the story of civilization subsequently wrote a slim monograph the lessons of history a theme of the latter is that universal patterns in the sweep of history are surprisingly few but one of them is described as follows since practical ability differs from person to person the majority of such abilities in nearly all societies is gathered in a minority of men the concentration of wealth is a natural result of this concentration of ability and regularly recurs in history the durants admire the profit motive as a stimulant to economic productivity but because of the divergent marketplace aptitudes of human beings growing inequality from competitive market systems seems to be the eventual result the durants cite with nuanced approval the observation of karl marx that history is economics in action and conclude that the concentration of wealth is natural and inevitable and is periodically alleviated by violent or peaceable partial distribution their suggestion here is that the predisposition of social systems to eventual distributive justice is part of the pattern of history when that fact is not recognized early enough detrimental social upheaval may follow as martin luther king jr famously stated the arc of the moral universe is long but it bends toward justice however the process of arriving at that justice can be messy and anything but serene presently in one of the more discussed books of recent years capital in the 21st century french economist thomas piketty argues that the longrun rate of return on wealth exceeds the rate of economic growth from wages ie labor according to the piketty thesis since the already affluent classes control higher yielding wealth the rankandfile must depend on wages thus it appears that over time the rich tend to get richer and economic inequality increases assorted neoliberal and freemarket economists have attacked pikettys assumptions models and analyses but data over the past five years since the publication of capital have been supportive of the inequality thesis economist joseph stiglitz a nobel laureate warns that markets have not been working the way their boosters claim and that current inequality has reached a stage where it can be inefficient and bad for growth even within the marketing discipline a subarea of academic researchcritical marketing studies has emerged which indicts the marketing system itself cms studies collectively highlight some dysfunctions of marketing such as exaggerated product benefits dubious advertising claims customer manipulations exploitation of vulnerable segments and other chronic pathologies many systemic in recent years some consumers and other stakeholders often have not received fair treatment by any standard of justice volkswagen rigged internal software to underreport the pollution level of its vehicles wells fargo bank churned customer accounts to accumulate fees without customer knowledge facebook lied repeatedly about the access that app developers had to private customer data and its protection to name just a few examples each of these injustices took place on a massive scale and eroded the trust necessary for smoothly operating markets these practices constitute marketing for a lesser world such socially irresponsible marketing practices also represent the all too common market failures that a srm commitment to distributive justice might help to alleviate what are the lessons to be drawn from this brief excursion into the dj standard 1 justice since it is the quality necessary to morally assess resource allocations to participants in societya point first made by philosopher david hume appears an ethical standard well suited to evaluating srm 2 distributive justice in particular because it can address how economic rewards and penalties are divided among stakeholders seems an essential normativeethical framework to help establish the societal contributions of marketing activities 3 from societys standpoint the fairness of particular marketing policies and practices cannot be judged without scrutinizing the payoffs and tradeoffs among various entities stakeholders or upon the physical environment these evaluations ought to include the rawlsian difference principle which looks to how the most vulnerable stakeholders are being treated 4 while the manner and methodological process is challenging measures of dj to evaluate marketing issues can be constructed qualityoflife research is one such example with a distinctly macro flavor for assessing the fairness of outcomes deriving from different market arrangements in general dj is a macro ethical standard well suited to evaluating whether the social contract between business and society is being properly discharged 5 failure to address perceived issues of unfairness stemming from economicmarketing practices can engender systemic turmoil and disorder or even systemic transformations in how markets are allowed to develop and operate we now explicate the final definens of our unabridged definition of srm constructive engagement constructive engagement a macromarketing mindset for improving srm constructive engagement is a mindset regarding socially responsible marketing which is born from a macromarketing perspective it is an amalgam of policy and business practices that help identify and address via systemic longrun thinking interventions with marketing problems that create wins for both business and society the idea that ce is fundamental to socially responsible marketing was developed by shultz and colleagues mainly for application to developing markets in conflicted geopolitical marketscapes but because of the ability of ce to manifest a creative big picture orientation it also can be applied to assorted questions and issues concerning srm in most marketing situations constructive engagement can be thought of as macromarketing thinking in action it represents a reemphasis on broader systemslevel analysis of marketing questions with intentions to enhance individual qualityoflife and societal wellbeing if distributive justice as argued aboveis the moral measure of srm ce can be envisioned as its pragmatic partner providing direction for marketing managers and policy makers by motivating their focus on srm while satisfying economic and policy objectives because the application of a macromarketing mindset aids managers to better perceive what ethical and socially responsible marketing requires it is helpful to articulate the elements of constructive engagement shultz drawing from prior macromarketing literature lists the purview of constructive engagement as including systemic understanding recognition of historical lessons cultural empathy behavioral interdiction cooperation and a preference for marketbased solutions while realizing the possibility of market failures space does not allow a full sketch of the possible applications of ce elements but the brief review of ce philosophy below supplies its flavor constructive engagement usefully channels the fundamentally ethical character of the macromarketing perspective that is markets and marketing ought to improve society ce encourages marketers to address the social traps of shorttermism in marketing practice and to avoid the easy path of nonaction when social intervention appears called for some terse elaboration is in order by social traps we mean avoiding actions though profitable or otherwise beneficial in the short run that cause harm to society in the long run the archetypal example is the overgrazing of land held in community by allthe famously labeled tragedy of the commons social traps are emblematic of the pitfalls to srm because they reflect a mania of shortterm economic results that often lead to market outcomes not in the best interests of society a vexing result of succumbing to social traps is the generation of externalities resulting from marketing actions externalities are costs that fall outside the exchange equation and often accrue to parties that are not a direct partner in the market exchange marketers are seen as failing the betterment of society when their actions impose negative externalities on society examples of negative externalities flowing from marketing might include the cost of identity theft due to a marketers poor protection of consumer data city pollution from the sales of gasguzzling vehicles in urban areas better suited to mass transit the health costs resulting from unanticipated drug interactions when pharmaceutical companies hype new products and reckless wars that feed the militaryindustrial complex via weapons marketing and consumption the ce approach would hold that with macro thinking about systemic marketing outcomes marketers will be in a better position to avoid social traps and minimize negative externalities as laczniak and murphy have reminded in their portrayal of normativeethical precepts marketers are responsible for the actions they intend their means of implementation and their outcomes in other words marketers are ethically mandated to take ownership of the negexs they generate and there are also plenty of case examples when constructive engagement can both improve society and result in economic reward for the marketer by acts of omission we refer to situations where marketers choose not to engage in situations or systems when it is foreseen that because of that restraint the same negative result occurs in other words marketers striving to be socially responsible should constructively engage when they find themselves in a position to hasten positive social outcomes as they conduct operations the litany of action failures by marketers is as long as the tactics comprising marketing strategy for example failure to curb coercion in the channel of distribution not desisting from predatory pricing practices and neglecting to terminate controversial promotional campaigns could all be examples of failure to engage the cynic might well respond such boundless ethical obligation is meaningless however when limited to the confines of an individual firm the ethical duties of ce are less encompassing a mechanism to create a focal point for identifying marketing issues to be constructively addressed might be generated through stakeholder dialogue as previously mentioned a firms stakeholders are in good position to know the issues most affecting them nill and nill and shultz offer frameworks to tap stakeholder concern through a formalized communication system thereby providing a practical way for the key issues facing a given firm and its stakeholders to be identified and discussed through such a process situations where exchange fairness is in question can be inventoried a helpful illustration of the import for holding a macro mindset to constructively engage societal challenges can be gleaned from two recent lists of marketing problems in 2016 in an effort to sensitize marketers to major disciplinary questions that must be addressed the american marketing association released its first ever intellectual agenda of the seven big problems confronting marketing the list of big problems unquestionably comprises challenges that most marketing firms must grapple with if they wish to become more competitive in the future and certainly discerning how to address issues such as the digital transformation of the modern corporation and dealing with an omnichannel world are noteworthy concerns for many marketing practitioners but as a point of contrastand as an example of how constructive engagement from a macro ethical viewpoint can help marketers understand what might increase srmconsider the list of 7 wicked problems of marketing systems introduced at the 2017 macromarketing society conference on this list we find systemic threats such as invasions of consumer privacy inequality of market outcomes exploitation of vulnerable consumer segments and obstacles to sustainable consumption it is not unreasonable to ask addressing which list of problems will more likely lead to knowledge and insights that help marketers responsibly shape a better world for macromarketing scholars when market segments are encountered that evoke one of these issues the list can serve as a reminder concerning where ce may be needed to enhance srm while srm and shortterm economic gains can and do occur simultaneously the expectation for this outcome should be tempered there is substantial empirical literature not addressed in detail here exploring various srm strategies and their correlations with profitability of this research because of study design differences variable operationalization longitudinal parameters sample compositionsize and many other factors the most that can be said about the metarelationship between srm and improved financial performance is that it is unverified certainly there is cause for cautious optimism as socially responsible activities have been linked to increased customer satisfaction and reduced stock volatility but other investigations suggest that srm activity may have no impact or even negative influence upon product and brand perceptions scientific findings beyond marketing and basic logic suggest that spending fewer shortterm dollars on debatable products and endeavors that damage health and involve existential threatseg carbonbased energy weapons and warswhile allocating those same dollars to advance renewable energy health care and poverty reduction would in the long run result in a healthier and safer world ultimately the topic of constructive engagement requires some comment about its connection to various institutions in bringing about marketing outcomes that are socially responsible institutional theory has its roots in multiple disciplines including sociology economics and political science parsons an early and wellknown institutional thinker perceived organizations as legitimated by their bonds to other societal institutions in a variety of functional contexts for instance the earlier mentioned american marketing association and its statement on ethics is an example of a helping institution founded to aid industry practitioners the ftc the fcc and the antitrust division of the doj are us government regulating institutions that are charged with constraining unfair competition and leveling the playing field so that markets are fairer religious organizations are cultural institutions whose precepts help shape the boundaries of social expectations and establish behavioral limitations to dubious marketplace tactics marketers serious about srm must recognize that their strategic options are both enabled and constrained by institutions but regardless working with institutions to improve societal effectiveness is an important part of engaging constructively as economist okun wrote in equality and efficiency the market needs a place and the market needs to be kept in its place this disposition was similar to the countervailingpower idea that j k galbraith first explored to temper the power of markets and their unfortunate consequences when they fail without countervailing institutions it would not be in the market interests of an individual firm to make investments that protect the physical environment unless other competing firms were required to do the same without institutional interventions large firmsto capture monopolistic rentswould always be tempted to drive smaller less powerful firms from the market mcmahon detailed the concept that it is social institutions that provide the power to make distributive justice transformative stated differently when srm is lacking strong social institutions must provide the necessary remedies ce with its macro perspective recognizes that cooperation with societal institutions is essential and inevitablea point of limited discussion in too many analyses of microfirm behaviors what can we conclude from our primer regarding the integration of ce with socially responsible marketing 1 constructive engagement is a stateofmind that reintroduces macromarketing perspectives into the analysis of marketing issues it consistently reminds managers that srm has a societal mandate 2 ce implicitly recognizes that many marketing actions create externalities some of which are negative when the costs of marketing induced negexs are not internalized society or a particular stakeholder group bears costs they do not want andor did not anticipate this creates society vs marketing conflict 3 a ce outlook warns against shortterm thinking that leads to social traps ce encourages an actionoriented disposition to marketing problems that breeds proactive srm 4 the connection between socially responsible marketing and immediate positive financial outcomes is unclear whether adopting a ce orientation has an incremental effect on profitability also may be uncertain however a ce mindset will help marketing practitioners to anticipate the costs of possible ethical disasters and to avert existential threats in the forms of societal degradation environmental destruction climate change pandemics and apocalyptic warfare 5 ce involves goodfaith engagement with social institutions of various kinds in order to impel srm actions that otherwise would be spurned as economically inefficient toward a doctrine of srm observations and considerations this completes the formal explication of a normative definition of socially responsible marketing the previously primitive elements of srmcorporate citizenship stakeholder orientation and socialecological sustainability have been examined and made to be less primitive and more transparent with the fundamental exposition of the social contract as the rationale for srm distributive justice as an important ethical measure and constructive engagement as its pragmatic compass we have pulled together an integrated assembly of concepts that should be crucial to understanding the nature of socially responsible marketing this comprehensive definition of srm while firmly anchored in the literature is unapologetically macro normativeethical and thus idealized nevertheless for scholars analyzing srm behaviors these elements ought to help portray a more complete picture of the dimensions that should and must be examined the srm definition we have explicated is a normative social constructan ideal when such ideals are further examined they have the capacity to affect social change moore observed that …the disparity between the ideal and the actual provides the probability of innovation and the probability that some innovations whether deliberate or by chance will be acceptable in other words the pieces of this explicated srm definition will hopefully help reveal new vistas for srm as they might affect the marketing system as yadav emphasized we intend that our logic of exploration inspires a future logic of discovery thus when marketers want to examine if a particular marketing practice is socially responsible or makes for a better world they need to inspect that phenomenon in light of our normative definition of srm and with the fullness of its compositional elements academic marketing scholars also should compare the empirical reality of current micro marketing practices with the macro ideals of srm when carrying out future streams of research this exercise of definitional explication does not yet yield a set of systematic testable propositions about socially responsible marketinga theory of srm however assorted clues and blueprints about building a comprehensive doctrine of srm can be gleaned from the takeaways listed after each elements explication how these pieces might integrate with one another deserves further thought and research exploration by marketing academics such collective exercises can lead to advancements about how basic srm might be better measured and how these dimensions are inextricably moored to the zeitgeist of a social contract reflection upon whether the marketingsociety social contract is properly functioning should also result in an appreciation of distributive justice as the moral measure of marketing and the cultivation of a macro mindset of constructive engagement we are hopeful that our fellow marketing scholars will embrace the challenge of formulating and developing hypotheses about how srm is enhanced or diminished finally since the idea of marketing practitioners embracing their work as a calling to serve both customers and society was earlier addressed it seems appropriate to end with a short homily about the professional and ethical obligations of marketing academics as educators marketing academics have several interlocking responsibilities these involve seeking and stating the truth about their subject of study exercising scholarly competence to enhance the understanding of their discipline and enlightening and motivating their students to hold before them the best ethical standards of their professions for business academics including marketing professors accreditation standards such as those of aacsb international also require that ethics and social responsibility be treated within the business curriculum this implies that education about social responsibility cannot be outsourced to other parts of the university and indeed as of late 2016 over 650 business programs in 85 different countries have committed to featuring socially responsive education in their coursework by agreeing to teach the prme approachprinciples of ethical sustainable operations based on the previously discussed un global compact and sdgs the urgent message here is that serious examinations of srm cannot be shunned by marketing academics without a charge of dereliction of professional duty almost 70 years ago vaile grether and cox presciently wrote about marketing as a transcendent social institution and advised we believe that students must be given a clear understanding of why marketing exists as well as how it is carved out in the american and presumably global economys dynamic mixture of public and private enterprise and that they must be able to come to some judgment as to how well it discharges both its social and economic tasks recognizing and embracing a comprehensive definition of socially responsible marketing would appear to be a first step in that process endnote our methodology for systematically justifying a definition a elucidate the payoff of greater definitional explication segerstedt said it well long ago when a word is defined the meaning of the word is stated definitions of scientific terms consequently must be explanations of the meaning of terms…we must remember that a word has meaning only within a language systempeople using that language behave in a certain way toward the object as the object is perceived as equipped with certain properties we cast this definitional development directly within the framework of macinnis who writing in the journal of marketing helped classify the types of conceptual contributions in marketing scholarship that advance knowledge our discussion of srm falls squarely into her category of explicating whereby we will methodically describe the fundamental nature of socially responsible marketing its antecedents its processes a theoretical standard of assessment and a pragmatic orientation for maintaining a srm focus we concur with macinnis who connected the delineation and explication of significant concepts in marketing to subsequent advances in research through delineation complexities are realized that in turn require differentiation which insures deeper thinking clarity from differentiation gives way to agreedon views that are advocated and seem true subsequent thought may give way to a revised perspective with summarized views on the revised perspective giving way to an integrated perspective and …the identification of novel ideas b specify the theoretical richness of an improved nominal definition following hunt and other philosophers of science this development of theory unfolds with a literaturerooted nominal definition of srm that might ultimately lend its conception to operationalization axiomformation and empirical testability our nominal definition consists of a definiendum and also the definiensits rules of replacementthat is the assortment of other key elements which if exchanged for the definiendum would maintain the truth value of the term at focus in our exposition the elements of corporate citizenship stakeholder orientation and socialenvironmental sustainability will comprise the basic essence of the definiens for academic marketers trying to come to grips with the question of whether particular categories of marketing practice serve the greater good a more sophisticated understanding of what dimensions constitute socially responsible marketing seems necessary as hempel wrote about concept development in social science the growth of a scientific discipline…always brings with it the development of a system of specialized more or less abstract concepts and corresponding technical terminology thus what needs to be ascertained about whether various practices in marketing are responsibly contributing to a better more ethical world is an enhanced detailed and theoretically defensible definition of srm that circumscribes its basic nature as philosopher of science rudner has observed while definitional systems alone are not testable theories clarifying the primitive element that comprise definitions has probably been an important criterion of the acceptability of theories throughout the history of science c delineate the elements essential to a comprehensive definition of srm concept richness depends on specifying properties or characteristics that are useful relatively complete and that eventually will aid the operationalization of phenomena under scrutiny to this end in addition to the three aforementioned definens elements our explication of srm also will include its theoretical justification a normativeethical standard for its evaluation and an elaboration of how socially responsible marketing is pragmatically advanced from a macromarketing standpoint these additions greatly strengthen our proposed definition of srm by supplying its rationale the rules to assess it and a recommended protocol to improve it returning to macinnis good conceptual papers in marketing are those which explicate and delineatethat is consider factors that circumscribe the entitys study or moderating conditions that may affect it thus the definition of srm that is posited below is intentionally idealized and aspirational writing about the theory building process berger and luckmann have asserted that questions concerning what fully constitutes a social science construct must surely rest on the values and the valueladen dimensions of its nature as much as what might be established via empirical study relatedly searle has observed that when it comes to larger institutional level concepts the normative and the positive are necessarily linked in order to understand how the world does work in comparison with how society maintains it ought to work e position the definitional postulation in the context of extant marketing theory the notion of srm that we endorse embodies several metatheory attributes argued to be important in marketing theory sheth gardner and garrett advocate looking at certain key characteristics when analyzing theoretical marketing frameworks accordingly and consistent with sheth et al the definition of srm explicated in this paper is particularized in a structured fashion improving its potential to enhance future testability and also demonstrates a richness in its range of application to srm this definition of srm is exceptionally robust because it identifies the theoretical anchor of srm as the social contract and its three elementscorporate citizenship stakeholder orientation and socialenvironmental sustainability is put forward as a pertinent ethical standard of assessment constructive engagement is ventured as the protocol for keeping a srm focus explicating and justifying a definition of srm thus becomes the essential step of theoryinformation with respect to advancing and understanding a doctrine of srm declaration of conflicting interests the author declared no potential conflicts of interest with respect to the research authorship andor publication of this article

in this conceptual article the authors use a macrolevel analysis and normative ethical theory to delineate and to explicate a doctrine of socially responsible marketing srm applying a theoryinformation approach we postulate a literatureinformed definition of srm we discuss why a macro and normativeethical rather than a micro and positivedescriptive perspective is essential to justifying the elements of srm we explore and explain why the roots of an authentic doctrine of srm can be discerned from the literatures of marketing history corporate social responsibility institutional economics and moral philosophy in so doing the mandate to engage in socially responsible marketing is shown to be anchored in a social contract this conception offers three essential elements of srmcorporate citizenship stakeholder orientation and socialecological sustainabilityeach of which augers a prosocial rather than instrumentalfinancial approach to marketing practice we recommend a specific normativeethical standard embodied in distributive justice to best evaluate srm we counsel adopting a macromarketing perspective of constructive engagement for those seeking responsible marketing for a better society and world finally we offer a short research agenda for advancing marketings embrace of srm

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introduction the china disabled persons federation estimated that at the end of 2010 approximately 85 million people in china had disabilities 1 china has the largest disabled population of any country in the world research has estimated that the total number of disabled people in china will reach 165 million which is almost double the current number by 2050 2 the healthy development of such an enormous number of disabled people requires effective social support social support can positively affect selfesteem and selfefficacy as well as promote many positive emotional behavioral and health outcomes across an individuals life span 3 researchers have had high expectations of computermediated communication as a means of providing social support 4 while cmc scholars have produced a plethora of studies on different aspects of online behavior and outcomes studies focusing on the online behavior of people with physical disabilities have only recently begun to emerge 5 indeed online social support will change with developments in ways of socializing on the internet 6 the number of online video watchers in china had reached 995 million as of june 2022 which accounts for 946 of the total number of chinese internet users 7 considerable amounts of these videos are created by people with physical disabilities at the macrolevel the chinese governments disability policies are not based on a social model but rather on an individualoriented model whereby disabled people must rely primarily on themselves rather than on the government 8 this unique context prompts people with physical disabilities to actively use new communication technologies such as online videos for social support in addition past research has found that online interactions can help increase the level of perceived social support and improve peoples psychological state and health 5 social support for people with disabilities is not robust in developing countries and emerging online technologies have the potential to enhance perceived social support for people with disabilities in a broader sense online video creation by people with physical disabilities can not only bring social support to themselves but can also benefit a wider audience of viewers with disabilities and even ablebodied audiences therefore it is worth exploring the behavior of people with physical disabilities in using online videos to obtain social support in the chinese context it should be further clarified that video creation by people with physical disabilities is only the starting point of this study the social interactions between people with physical disabilities and online video platforms followers viewers and sponsors as well as the perceived social support in the process are the focus of this study the development of online social support social supportthe various resources provided by ones interpersonal ties 9 has been recognized by the health community as a means of promoting and restoring health and wellbeing 10 since the concept of social support was initially proposed a large number of studies have aimed to reliably confirm the link between social support and physical health 1112 at present sufficient evidence has shown that effective social support can promote recovery from various diseases 13 with the rise of online networking scholars have found that seeking social support is one of the most important reasons for people to socialize online 14 a study found that social networking service users feel higher levels of emotional support and companionship than ordinary internet users 15 a growing number of scholars have conducted increasingly specific research on online social support many of these studies have focused on online social support groups on different platforms such as whatsapp and facebook 16 twitter 17 and instagram 18 online groups can provide just in time support overcome geographic barriers and facilitate open discussion of health concerns 19 at the same time online video platforms have revolutionized ways of socializing and have brought new means of social support researchers have found that online videos provided a strong sense of presence and connection even when viewed asynchronously 20 and that there was a high intensity of connection and emotion thus opening up possibilities of new forms of online social support 21 gómezzúñiga and fernandezluque 22 found that epatients youtube videos created a peer community for patients met patients informational and emotional needs and increased patients senses of selfefficacy tu and zhou 23 found that young people with cancer received emotional care identity reconstruction and selfworth material rewards and therapeutic assistance through tiktok short videos thus transforming marginal support from strangers into core support in the real world salib et al 21 pointed out that while researchers have observed health videos on online video platforms little is known about social support associated with online videos in addition a growing number of studies have focused on online social support groups for specific conditions such as postpartum depression 24 irritable bowel syndrome 25 huntingtons disease 26 hivaids 27 breast cancer 28 tourette syndrome and tic disorders 29 however research on online social support for physical disabilities is insufficient 5 social support is even more important for populations with physical disabilities because they are particularly dependent on the help of others while individual experiences and circumstances vary widely the reduced mobility reduced socialization and social isolation that can result from physical disabilities are common 30 although a variety of studies have investigated social support most of them have been biased toward the structure or function of social support structural aspects of support are the perceived existence and number of support providers whereas functional support refers to the perceived quality of support 31 researchers have argued that the measurement of functional support leads to a more relevant and valid representation of the quality and role of social support 9 most representatively house 32 identified four forms of functional social support these forms of functional social support are still being researched and expanded by scholars studying online social platforms and the functional types of social support that act on perception play a more effective regulatory role for individuals 33 therefore it is necessary to adopt a selfreported approach to social support for research 34 access to online videos by people with disabilities recently a growing number of people with disabilities have expressed various aspects of living with disabilities through videobased social media platforms that focus on media sharing 35 when compared with traditional media technology the potential of usergenerated online videos lies in the opportunities it presents for online selfexpression and exchange that is open accessible compelling unconstrained and unmediated 36 current research has focused on three aspects of the online video usage behavior of people with physical disabilities first some scholars have analyzed video content created by people with disabilities to investigate how these users present themselves and construct identities examples include discussing identity formation and identity management of people with disabilities in video game streaming 37 disclosures of selfdifficulties by people with disabilities on youtube 38 and visually impaired bloggers experiences in online video communities 39 second some studies have noted the inclusivity of online video platforms for people with disabilities ta 40 made a normative case for why internet video creation should be accommodating of accessibility for people with disabilities and proposed how this ideal might be achieved with the inclusion of a road map of the technical legal and social hurdles that must be overcome rong et al 41 found that tiktok has an algorithmic bias against blind or lowvision anchors and proposed that a more inclusive and fair live broadcast platform should be designed third the use of online videos to obtain social support by people with disabilities has attracted the attention of researchers bromley 42 analyzed youtube videos created by people with disabilities and argued that these videos function as informational support for other people with disabilities johnson 43 interviewed disabled anchors on twitchtv and found that live streaming brought them employment and moneymaking opportunities libin et al 44 found that the popularity of howto videos posted on youtube by people with spinal injuries boosted these users senses of selfefficacy although online video platforms have become a key medium for people with disabilities to express themselves and obtain social support 35 few studies have discussed in depth how people with disabilities perceive social support through online video platforms in china online video platforms such as bilibili and tiktok have emerged with numerous users 45 the popularity of online videos has inspired a large number of people with disabilities to create videos according to media reports many disabled people who have no access to traditional workplaces due to time and space constraints are finding employment by creating online videos 46 previous studies have pointed out that under the dominant disability discourse of kao ziji in china disabled people lack direct support from the state rather the responsibility is left to the families of disabled people and to disabled people themselves 47 however china is currently undergoing a family structural transformation with a declining birth rate and aging population which has made family risk expansion and family support fragility more obvious 48 therefore disabled people in china value the social support provided by online video platforms on this basis it is worth studying the use of online videos by chinese people with disabilities especially those with physical disabilities to obtain social support despite the urgent need to explore this area there are few related studies given that online video provides a new mode of communication and social support and that chinese people with disabilities are actively using online video platforms to gain social support it is important to understand how for example people with disabilities obtain social support through online videos evidence of the social support provided by chinas emerging online video platforms remains limited so research on these platforms is warranted as online video platforms such as youtube are not easily accessible from within the country the present study the abovementioned studies have provided some research evidence that people with disabilities are actively experimenting with online videos and that online videos can provide some social support for people with disabilities however there are some limitations most studies on online social support have focused on the dimension of structural social support and research on perceptual social support needs to be strengthened most relevant research has focused on social support on social platforms such as twitter but there has been little research on how people with disabilities use online videos to obtain social support the only studies on the use of online videos by people with disabilities have focused on developed countries with relatively mature social support systems however social support systems for people with disabilities in many developing countries are still far from perfect and how people with disabilities obtain social support through online videos has not received sufficient attention previous studies on the use of online videos by people with disabilities have basically focused on the inclusiveness of digital technology or the identity construction of people with disabilities and have not taken social support as the main perspective and most relevant studies have focused on the positive effects of online videos on people with physical disabilities and have paid less attention to the possible negative effects in view of the fact that there are many classifications of disabled persons for this study physically disabled people were selected as the research object and qualitative research was used to explore how physically disabled people use online videos to obtain social support without setting any research assumptions as mentioned above the social context and video platforms experienced by disabled people in china are special this study is not aimed at a specific platform but instead explores broader online video social support the aim is to address the following questions in china which is a developing country with an imperfect social support system for disabled people why do people with physical disabilities choose online video creation to obtain social support how do people with physical disabilities build social support through online video creation what kind of social support do physically disabled people receive through online video creation and what are the potential risks of this social support materials and methods study design a qualitative research design was used for this study qualitative inquiry can facilitate new areas of research by providing descriptive insights into the nature or meaning of everyday experiences 49 over the past few decades there has been a clear qualitative methodological shift in disability research 50 attention has shifted away from the medical or rehabilitation definitions of disability as physical impairment or vocational restriction to a new definition of disability as a product of the interaction between the individual and the environment 51 from this perspective qualitative research can help to better disentangle the compounding effects of social economic and cultural barriers on overall health status and the health of people with disabilities 50 maxwell distinguishes between internal and external types of generalizations the findings of qualitative research seek generalizability across settings or groups without pursuing overly generalized external generalizations 52 therefore this study did not formulate a research hypothesis but rather examined an indepth analysis of information on a specific topic the semistructured interview is a commonly used data collection method in qualitative research the combination of semistructured interviews and openended questions enables interviewers to navigate flexibly and explore the practices and feelings of people with physical disabilities who use online video creation to obtain social support as well as allows new topics of conversation to arise 53 the semistructured interviews employed in this study were designed to investigate the reasons processes outcomes and other perceptions of participants in obtaining social support through online video usage the interview contained five main questions why do you use online video platforms how do you use online video platforms have the online video platforms brought you social support and what kind of social support have they have brought has creating online videos effectively provided you with social support and why what negative experiences have you had with online video creation ethics all interviewees provided informed consent to participate in the study and were assured that their data were anonymous and confidential ethical approval for this study was obtained from the institutional review board of social sciences and humanities of jinan university this research was conducted in accordance with the declaration of helsinki all data collection conformed with data protection regulations data analysis thematic analysis was used to analyze the qualitative data from the interviews thematic analysis is a method for analyzing qualitative data that entails searching across a data set to identify analyze and report repeated patterns 54 thematic analysis consists of six stages becoming familiar with the data generating initial codes searching for themes reviewing themes defining and naming themes and producing the report it should be noted that in order to eliminate researcher bias and prejudice the authors invited a sociology professor of sociology and a graduate student of journalism and communication both with a good research trajectory to analyze together analytical rigor was ensured by the analysts scrutinizing comparing and discussing the coding to resolve any discrepancies identified the agreement on the content analysis was assessed and was high 55 computerassisted qualitative data analysis software was used and the interview transcripts were input into nvivo version 11 results two major themes were identified through thematic analysis social support for online video creators with physical disabilities and risks of social support for online video creators with physical disabilities the first theme focused on why and how people with physical disabilities gain social support through online video creation and the second theme revolved around the hidden risks for people with physical disabilities in gaining social support through online video creation under each major theme are subthemes expressing meaning and attributes the subordinate themes of theme one are meeting emotional needs obtaining informational support obtaining creative benefits constructing identity reconstructing social relationships and discovering selfworth the subordinate themes of theme two are online language violence invasion of commercial capital online video addiction and fragile social support given that this was a qualitative study the exact numbers were not necessarily important since qualitative research does not attempt to generalize the findings however words are sometimes used in this study to indicate approximate numbers most many some and a few social support for online video creators with physical disabilities meeting emotional needs due to their physical impairments people with physical disabilities are prone to negative emotions such as anxiety and depression 56 online videos are easy to create and provide them with a channel to record and express themselves which can meet their emotional needs to a certain extent all participants mentioned in the interviews that creating online videos provided them with a sense of companionship that they lacked in real life its not easy to take care of family members they have their own things to do and i dont want to pass on some of my bad emotions to them so i will use tiktok to record some of my emotions tiktok can record with one click for short videos and i use tiktok as a daily recording tool when i tell the joys and sorrows in my life i will receive some likes and comments and i feel as if someone will always be with me my legs cant move and especially during the lockdown period i cant go out so i often feel very lonely but fortunately i have become a tiktok anchor although i only have a few thousand fans but in the live broadcast room there is always an audience listening to my story which makes me feel a sense of companionship by creating short online videos people with physical disabilities can be seen by more people while watching the videos viewers encourage and express caring for the physically disabled creators through danmu comments and private messages most of the interviewees mentioned these comments i often share videos of me dancing with prosthetics on tiktok at first i thought that people would be afraid to see the crippled body but then i found that many people encouraged me and praised me for dancing well almost every day i see encouraging sentences in the comment section and private messages that make me feel warm since the spinal injury i have been paralyzed in bed and life suddenly became very difficult for me in order to allow myself to persevere i started to share on bilibili how to relearn life skills after being paralyzed many strangers encouraged me through danmu comments such as we will always support you and come on everything will be fine obtaining informational support people with physical disabilities usually undergo longterm rehabilitation during which they need considerable social informational support in addition to professional informational support from doctors the interviews revealed that people with physical disabilities can obtain effective informational support both active and passive when creating videos all interviewees indicated that they shared their experiences and knowledge related to disability in their video creations before becoming video creators they had usually collected much relevant health care and rehabilitation information online thus ensuring their own knowledge all participants mentioned proactive knowledge gathering for the purpose of creating online videos as an important motivation to obtain informational support for themselves in order to become a qualified short video creator i watched almost all videos related to lowerlimb disabilities on the jitterbug platform during this time i also went to specialized rehabilitation websites for people with disabilities despite all my own years of experience i was still worried that the rehabilitation methods i shared were not scientific and would mislead the audience in the process i grew into a half expert myself i usually watch videos on spinal injury rehabilitation and speak this knowledge to the viewers during the broadcast in the process of learning and explaining i not only feel that my knowledge about the subject has grown but i also feel that i can better understand and manage my health condition many participants indicated that online information was not reliable and that informed viewers added to or corrected the information they shared through comments of course viewers with specialized knowledge backgrounds sometimes responded to the online videos and offered targeted advice to the video creators in this ongoing interaction the information provided by viewers served to support the creators of videos on physical disabilities when i was preparing to buy a prosthetic i saw some information online about prosthetic reviews and shared it in a video later several viewers who had been wearing prosthetics for years left me messages telling me that the information was actually advertising and marketing and recommended reliable information for me to buy prosthetics i was sharing my experience of studying counseling in the video and happened to meet a viewer who was a counselor he shared a whole audio course on learning about counseling with me in his message and i listen to one every day 313 obtaining creative benefits participants also described how they earned income by creating online videos all of the interviewees indicated that they were discriminated against when seeking work because of their physical disabilities but that online video creation provided them with the possibility of earning money the interviewees initial motivations for creating online videos were the desire to be paid but only nine interviewees actually admitted to earning some income five interviewees said that they had obtained a high number of fans and views through continuous online video creation then webcast companies found them and trained them to be professional anchors i have searched for a job more than a dozen times every time the company sees my mutilated lower limbs they will doubt my ability to work i am good at playing games and then i try to be a game anchor anyway in the game live broadcast the audience couldnt see my legs after the number of fans exceeded 30000 a live broadcast company contacted me i officially got a job as a game anchor and tasted the joy of working and making money in 2019 when live webcasting with goods had just emerged i joined it with the mindset of trying it out i was not professional at first and had several thousand fans watching but the volume of trading was low later a livestreaming platform recruited me and trained me professionally and only then did the revenue slowly improve four interviewees considered their ongoing online video creation to be a freelance job although the income was not high it basically met their living needs the numbers of likes and views on the online video platform did not provide much income and the income obtained by the interviewees mainly came from rewards and donations from the audience after watching the videos i tried to work in a restaurant kitchen before but the work was too intense and my body couldnt support it in comparison i think online video creation is very freeing and i can shoot with a mobile phone i dont have many fans but every time after sharing my daily life a few fans will reward me i will post some popular songs that i cover on bilibili and fans who like me will join the corresponding fan group some fans will send red envelopes in the group to support me and sometimes they even initiate donations to support my activity constructing identity another theme that emerged from the qualitative analysis of the interview data was the construction of identity all interviewees agreed that online video creation facilitated their selfidentity previously the identities of people with physical disabilities were shaped by mass media and other media and these images were often distorted through online video creation people with physical disabilities could take the initiative to present their image and to a certain extent break these social stereotypes for a long time social culture has called us useless people thinking that we are incapable mentally retarded and have weird behaviors in fact we are only physically disabled not social waste on bilibili i am a food blogger i boldly admit that i am a disabled person taste all kinds of delicacies and let the audience see a disabled person who loves life not a useless person who is desperate i grew up under the strange eyes of others and many media and novels also vilify dwarfism i used to feel that fate is unfair and i would rather die than live later i saw that there are actually many people like me on the internet and they are all struggling to live so i tried to record my daily life in the webcast and challenge myself to do things that i never dared to do before i know im getting used to showing myself and accepting myself in the studio it is worth noting that three interviewees mentioned the role of official media in constructing the identity of physically disabled people the official media reposted some of their videos which aroused widespread praise on the internet and brought them a large number of fans the interviewees said that this represented their recognition by official media which not only helped to reshape societys perception of physically disabled people but also increased the ability of physically disabled people to construct their own identities the local disabled peoples federation forwarded the video of me dancing and invited me to perform on the show on the national day of helping the disabled which helped me increase tens of thousands of fans i think this is a kind of affirmation of me and the surrounding friends seem to have changed their views on my identity because of this incident from pitying me to praising me i didnt expect that one day my video would be reposted by national media and they were all amazed at my experience of teaching myself counseling while paralyzed in bed at this moment i felt that i accepted who i am and showed more people that people with physical disabilities also have a purpose in life i feel that we are living in a forgotten corner the reports on me by the official media gave me hope i know that i am being watched and i begin to accept myself reconstructing social relationships participants also described the impact of creating online videos on their social relationships most participants believed that the low selfesteem associated with physical disabilities made them intentionally avoid social interaction and that online videos gave them the possibility of restructuring social relationships two interviewees emphasized that creating online videos can build a virtual community for disabled people to eliminate the pressure of real social interaction interacting with normal people made me feel stressed and i would internally complain about why i was made disabled but through video creation i met a lot of people with physical disabilities just like me when i talk and share with them i feel that this should be the social relationship i need its hard to see people with physical disabilities in real life and they prefer to stay at home but the online videos i create provide a virtual gathering space where we can socialize without leaving our homes most respondents believed that online social relationships established through online video creation can be translated into offline relationships i am very lucky it is impossible to have so much dwarfism in real life and it is impossible for me to find a normal person to marry i created funny videos and met her who also suffers from dwarfism among the fans then we developed from online to offline and we got married after getting along for three months a fan left me a message after watching my video she has the same lowerlimb disability as me and lives in the same city after we added wechat to each other we made an appointment to do rehabilitation training together now we have developed into good sisters two other interviewees described the impact of online video creation on family relationships the online social interactions that developed through video creation allowed them to come out of their selfimposed isolation and eased strained family relationships my parents were worried about my mental state and they were afraid that i would selfharm or commit suicide because i couldnt think about it in the video creation i met many people like me i started to go out of my own world and my parents were very relieved i have met many friends in video creation i have become more cheerful and my family no longer takes care of me all day long i also tell my family funny stories about the process of creating the video which provides us with more topics to talk about and enhances the relationship between my family and me 316 discovering selfworth participants also reported discovering selfworth in the process of creating online videos most participants believed that online video creation provides opportunities for people with physical disabilities to learn knowledge and selfdisplay which contains the possibility of selfrealization i not only create videos on the internet but i also use the internet as a learning library my video shooting editing and promotion methods are all learned online i will summarize and apply various popular video creation skills through continuous learning the number of views and fans of my videos have increased and i think these data reflect my value one participant believed that selfworth is the ability to make money and only when he could make money did he feel his own value in a market economy money is valuable i still cant forget the first income that video creation brought me i think i can finally make money with my own ability and i am no longer a waste other participants described feeling wanted because of the videos they created disabled video creators can find selfworth because of the needs of audiences especially ablebodied audiences most of my fans are actually ablebodied people who find the stories in my videos inspiring and bring strength to them sometimes i still get private messages from fans thanking me for bringing them out of their slump with my videos i feel like i am needed by everyone in the live broadcast room many viewers admired how a disabled person is selling goods as soon as they came in the audience may be attracted by my body at first but then they will be infected by my content i have some loyal fans mostly ablebodied viewers who make me feel included in society in addition another interviewee talked about how creating videos changed his aesthetic vision creating videos requires the frequent discovery of beautiful things around him which has changed his perception of himself and the world around him to a great extent although my lower limbs are disabled i am an outdoor anchor and my purpose is to challenge myself to shoot outdoor videos you must have the ability to discover beautiful things around you while walking the longterm shooting also trained my vision to discover the beauty of life when i feel the world is interesting and beautiful i feel like im shining too risks of social support for online video creators with physical disabilities online language violence when talking about the social support that comes with creating online videos some participants repeatedly mentioned the negative emotional experience of online verbal violence one participant reported in detail his experience of online verbal violence i am a food blogger and the food is in great contrast to the dwarfism i suffer from so when i first created the video i often had to face language violence every time i open the message area i always see comments accusing me of being ugly polluting food and begging on the internet for almost a year i couldnt get over my selfdoubt another participant spoke about the discrimination he experienced during the webcast one time i was randomly connecting with other anchors in the live broadcast room but the other anchor entered the live broadcast room and saw my physical condition said its so unlucky im mentally handicapped and left when asked how to deal with the negative emotions caused by this kind of online language violence the participants commented that there is no good mitigation mechanism for this kind of negative emotion and they can only rely on actively ignoring such comments selfregulation and comfort from other viewers we are not top creators and the platform doesnt care about us when encountering this kind of language violence its best to just ignore it if i replied to every negative comment then i would definitely be trapped in negativity and my life would be even grayer there is also verbal violence in real life just think more about happy things if i encounter comments that attack me i will simply delete them in fact most of the viewers are very loving when they see this situation they will firmly support me and comfort me sometimes they even help me to report these people invasion of commercial capital many participants spoke about the impact of commercial capital on video creation they believed that on the one hand commercial capital provides rewards and on the other hand it also creates troubles that cause them to feel alienated one participant talked about his experience of being forced to make false sales for a merchant no one can make money from live broadcasting let alone a disabled person like me later an online store contacted me and asked me to help sell some products with quality problems and i could share some profits from it at that time in order to make money quickly i had to do this some participants also said that commercial capital induces people with physical disabilities to create videos of miserable ugly and vulgar performances this deviated from the original intention of the interviewees to reconstruct the identity of disabled people but in order to make money they occasionally took the initiative to create related content im not really good at playing the game but the audience thinks its awesome to be this way as a disabled person sometimes in order to get the audiences attention and reward i will tell my disability experience over and over again and deliberately add some miserable episodes im a dwarf everyone thinks im ugly and deformed so the media company i work for always asks me to play some ugly characters although i reject it in my heart i understand that many viewers want to see my ugly appearance now in order to make money i began to take the initiative to sell ugliness another participant described the guidance of platform traffic and algorithms to creative content if vulgar content that can bypass online censorship is added the clickthrough rate of the video will be better and the algorithm may recommend it to more users many viewers watch female anchors actually to watch vulgar content that plays rubbish i found that dressing sexy doing some sexually suggestive actions and saying some sexually suggestive content will get more viewers to click the algorithm will also add you to the tags of sexy girls sexy dancers or disabled girls for pushing but you have to master a set of unspoken rules to bypass online censorship or you will be blocked online video addiction some respondents used the word addiction to describe their creation of online videos and the consequences in addition many respondents described the risk of loss of control in terms of realistic social and physical rehabilitation for example one interviewee believed that the convenience and speed of making friends in the live broadcast room had made him start to separate from real social interaction in the live broadcast room i can always find someone who is willing to listen to me and have feedback but in real life it is not easy for someone like me to find a listener i am becoming more and more enthusiastic about webcasting and sometimes i even broadcast for more than 10 h in a row but i also obviously feel that i am out of touch with the real social life and this computer seems to trap me two of the participants felt that creating the video took so much time that it interfered with their physical recovery singing videos are difficult to make and you have to sing and revise the sound repeatedly generally speaking it takes at least 6 h to make a video with higher quality such a large amount of sedentary time compresses my recovery time i only have one hand to use and it is difficult for me to make short videos for example others can type and edit with both hands but i can only type on the keyboard with one hand it basically takes a day to make a video and the recovery exercises have been interrupted for a long time in addition many respondents indicated that they are very concerned about the playback data of the videos they create they report checking for new likes and comments every few minutes making them feel as if they have been hijacked by the web feed one interviewee described his own experience in detail as long as i release a new video i will keep clicking in to check the likes and comments of the video there are no new social updates but i still cant help but check it every few minutes worrying about missing something this kind of behavior made me feel out of control i knew it was a waste of time but it was hard to control myself fragile social support a final theme reported by participants was the fragility of social support gained through online video creation most participants believed that online social support is uncertain and transient three participants shared their concerns about the sustainability of social support for creating videos including factors such as personal age content quality and shifting online platforms im young now and everyone likes to watch me sing and dance but in a few years when i get older my fans may not like me anymore what should i do then i broadcast four times a week but my stories are limited fans who just joined the live room may be curious about my story but slowly they will lose interest in me and i can feel that i am losing my fans every few years we experience a major reshuffle of online livestreaming platforms i used to be an anchor in panda live and after this platform closed down i came to douyu however the most popular now is the short video platform represented by tiktok i worry that the platform i live on will one day also be eliminated and then my efforts in the past few years will be in vain some participants compared online and offline social support arguing that online social support is only a supplement to offline social support rather than a substitute like me being bedridden for years my family and friends need to take care of me and their support is definitely the first thing online videos are after all virtual and of limited direct help to me i just hope that i can open up a new space on my own by creating online videos internet space is fluid and there are far more people watching me than helping me maybe a few of them are infected by my emotions and they will help me further in contrast family and friends provide more lasting help discussion a large number of people with physical disabilities are becoming creators of online videos but little research to date has focused on how people with physical disabilities access social support through the creation of online videos for this study semistructured interviews were conducted with physically disabled online video creators and a thematic analysis of the interview results was conducted respondents reported six dimensions of social support perceived through online video creation including meeting emotional needs obtaining informational support obtaining creative benefits constructing identity reconstructing social relationships and discovering selfworth at the same time respondents reported perceived risks of social support during video creation including online language violence invasion of commercial capital online video addiction and fragile social support although participants reported both positive and negative experiences with social support overall they all confirmed that creating online videos was effective in obtaining social support as is consistent with previous research findings access to facetoface social support may be problematic for people with disabilities due to their physical condition mobility and communication limitations thus they turn to the internet for social support 57 the participants in this study believed that the lack of offline social support was the reason that they wanted to become online video creators and thus obtain supplemental social support moreover there is no substitution between offline and online social support they are complementary relationships previous research has shown that people with disabilities can use social media to create support groups 58 find experts on specific health issues 59 develop identity 60 gain knowledge 61 share emotions 62 and build friendships 63 while previous research has focused on social support on social media platforms this study extends the focus from social media platforms to online video platforms thus confirming that people with physical disabilities can meet their emotional needs gain informational support construct identity and reconstruct social relationships through creating online videos in addition three valuable findings were obtained from this study first there is no conclusive academic opinion as to whether weak connections in social media lead to effective social support a recent study noted that weak connections are considered less helpful for emotional support and informational support 64 in this study all interviewees were active online video creators with high levels of online involvement they perceived offline social support to be deficient and they sought online social support to compensate this finding is inconsistent with previous studies about social support from weak connections which have most likely ignored the impact of the reality of the situation of seeking social supporters and the participants level of online involvement of course this finding needs to be further verified by subsequent quantitative studies in addition a previous study noted that synchronous interactions can lead to stronger community cohesion and emotional energy than asynchronous interactions 65 participants in this study also mentioned the differences in social support from synchronous versus asynchronous interactions in online video however participants did not specifically describe the differences between the two which warrants further study second previous studies of social support on the web have identified the existence of support groups 66 the participants in this study did not explicitly mention support groups but they believed that popups and messages in online videos actually functioned as support groups to some extent as interviewees m1 and m7 said in online video creation we can throw out our questions in a targeted way and there are always viewers who will give replies in popups and messages just like posting and replying in the disability community before at the same time while traditional online support groups tend to have a homogeneous group of patients 67 the findings of this study indicated through interviews that online video support groups tend to be composed of ablebodied individuals rather than those with the same physical disabilities as the participants further data analysis revealed that the temporary social support groups constituted in the online videos transformed into longterm fan communities for example creators often announce how to join their fan communities in their videos in order to gain more sustained social support third this study found that people with physical disabilities gained creative benefits and discovered selfworth by creating online videos which is a type of social support that has been overlooked in most previous related studies the qualitative data analysis in this study showed that earning income from creating online videos is a very important form of social support for people with physical disabilities all participants reported that even though they were not currently earning income from creating online videos they still harbor the hope of being able to do so this can be further explained by previous research on people with disabilities and employment earning income through work is a sign of inclusion and participation in society for people with disabilities 68 however the chinese government has not actively protected the employment rights and related benefits of people with disabilities in law instead leaving such responsibility entirely to disabled people themselves and their families 69 furthermore the governments encouragement of disabled people to use the internet for entrepreneurship and employment is part of a neoliberal policy of shifting social risk from the state to the individual in the wave of internet disability assistance in china 47 in fact only nine respondents in this study explicitly stated that they had earned income from creating online videos therefore the effects of entrepreneurship and employment through the creation of online videos by people with physical disabilities need to be further studied people with disabilities are often stigmatized by the mass media as supercrips disadvantaged or victims of illness 70 an empirical study suggested that positive mass media coverage of people with disabilities enhances their selfidentity while negative coverage leads them to deny their disability identity 71 as is consistent with previous research the interviewees in this study also reported a significant impact of positive mass media coverage on their identities however they also repeatedly used increases in likes plays and followers to measure this influence which suggests that the identity elicited by mass media may be supplementary to traffic realization in addition participants repeatedly used the term official media rather than mass media which reflected their perceptions of the role of official media in legitimizing discourse in china previous studies have also pointed out the dominant role played by chinese official media in the legitimization of discourse 72 people with physical disabilities encounter risks associated with accessing social support through online video creation as is consistent with previous research this study found vulnerability to the verbal violence that abounds online this study also identified online video addiction that may result from the creation of online videos by people with physical disabilities previous research related to online addiction has focused on online addiction and applicationspecific addiction in youth groups and research on possible symptoms of online addiction in people with physical disabilities is lacking respondents in this study reported symptoms of addiction and their consequences during the creation of their online videos another valuable topic is the intrusion of commercial capital previous research has suggested that chinese women with disabilities are using performative bodies in social media to gain public visibility and resist being marginalized and stigmatized 73 however participants in this study described their own experiences of perceived body alienation by companies platform traffic and algorithms in the process of creating videos it is worth noting that physically disabled online video creators are not ignorant of these risks but are able to detect and take certain measures to cope with the sense of loss of control which is a dynamic game process that deserves further study strengths and limitations the present study has certain strengths in four areas first to the best of our knowledge it is one of the first qualitative studies to explore access to social support for people with physical disabilities through the creation of online videos and could contribute unique value for future more indepth related research second this study adds to the findings of previous research on access to online social support for people with disabilities particularly by providing revealing reflections on social support in weak relationships and the development of online support groups third this study indicates the importance of creative gain and official media coverage for people with physical disabilities to access social support which is an issue that has been infrequently discussed in previous studies fourth this study reveals the hidden risks in the creation of online videos by people with physical disabilities and identifies many topics that have been overlooked in previous studies such as addiction to online videos by people with physical disabilities the alienation of creators with disabilities by commercial capital and strategic resistance to online risks by people with physical disabilities however this study has some limitations first participants may have exaggerated or concealed certain behaviors or feelings related to creating online videos in the interviews this issue needs to be addressed even though the interviewers in this study had experience in conducting interviews for qualitative research second surveys and psychometric instruments were not used in the present study it is an exploratory study in which people with physical disabilities reported social support and its risks in creating online videos future research can take specific interventions to measure the effects of social support obtained by creators with physical disabilities participants reported social support and risk for different themes but did not rank these themes in order of importance a qualitative survey of a small sample is a necessary step towards conducting a largescale survey effort and future research with a large sample could determine the order of social support and risk for different themes third because this study is exploratory in the field creators with physical disabilities were not categorized by gender age degree of disability and time spent creating online videos which may have affected the social support they received in addition creators with different types of disabilities may obtain variable social support through online videos the participants in this study were people with physical disabilities and further research should to see if this result can be generalized to the disabled population conclusions this study used a qualitative design to explore access to social support through online video creation for people with physical disabilities in china as is consistent with previous research on online social support this study found that people with physical disabilities can access effective social support through the creation of online videos but it is accompanied by numerous risks future research could use different research methods to further explore this topic in addition future research on online video creation and social support for people with physical disabilities needs to consider individual differences and sociodemographic backgrounds as well as a more detailed analysis of different types of social support and risks in online video creation data availability statement the data presented in this study are available upon request from the corresponding author the data are not publicly available for reasons of privacy

background online video creation is becoming an option for many people with physical disabilities in china however few studies have considered how physically disabled individuals access social support through online video creation methods for this qualitative study semistructured interviews were conducted with 18 online video creators with physical disabilities the starting point of this study was video creation by people with physical disabilities with a focus on the social interactions between creators online video platforms followers viewers and sponsors as well as the perceived social support in the process results thematic analysis was used to identify six social support themes i meeting emotional needs ii obtaining informational support iii obtaining creative benefits iv constructing identity v reconstructing social relationships and vi discovering selfworth four riskrelated themes were identified i online language violence ii invasion of commercial capital iii online video addiction and iv fragile social support conclusions the findings indicate that although people with physical disabilities can obtain effective social support through creating online videos it is accompanied by many risks in addition the social support gained through creating online videos differs from traditional online social support eg changes in online support groups emphasis on creative gain prospect future research should perform more detailed analyses of different types of social support and specific risks of creation while taking into account individual differences and sociodemographic backgrounds

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serendipity is a category used to describe discoveries that occur at the intersection of chance and wisdom to quote the words inventor horace walpole it describes discoveries made by accidents and sagacity of things the observers 1 were not in quest of this paper brings together the work of philosophers of science with results of the empirical study of experiences researchers and others have had of serendipity including the reflections of practicing scientists in diverse fields i show that serendipity in science is best understood when looked at within the broader context of the scientific community rather than narrowly through the lens of individual experience at the level of the individual serendipity points to a discovery marked by a surprising insight at the community level the role of epistemic expectationsboth enabling surprise and determining the response to surpriseis illuminated in turn my approach has implications for how the scientific community ought to be structured in order to maximize the benefits of serendipitous discovery for scientists science and society i argue that serendipity is an emergent property of scientific discoveries describing an oblique relationship between the outcome of a discovery process and the intentions that drove it forward this definition arises from the close examination of several key features of serendipity relevant to its impact on the practice of science these features together provide a paradoxical picture of serendipitous discovery it requires both luck and skill and is both unpredictable and yet can be cultivated the purpose of this paper is to demonstrate that when the context of the scientific community is properly taken into account the individual experience of serendipitous discovery is no longer paradoxical in communities that allow diverse members opportunities to contribute to the production of knowledge there will both be more opportunities for serendipitous discovery and community members will develop the skills necessary to take advantage of those opportunities the first three sections of the paper address the relevant features of serendipity in science first serendipity has many variations analyses of serendipity commonly focus on an insightful cognitive connection made by a serendipitous individual however serendipity as experienced by scientists and by others consists of multiple kinds of connections including social relationships and timeliness further serendipitous discovery is a process rather than an event and can be marked by several intersections of chance and wisdom that enable the valuable outcome second serendipitous discovery is profoundly contingent upon contextual factors beyond the insight of the serendipitous individual because it is both contingent and inherently unpredictable serendipity can only be used retrospectively as a category to describe scientific discoveries further the insight of the individual is insufficient for bringing about a serendipitous scientific discoverysuch discovery processes are also dependent on environmental factors and the structure of the community of which the individual is a member it is within this complex network of interacting factors that the three elements of serendipity come together and it is from this complex network that serendipitous discovery emerges third serendipity occurs when the limitations of epistemic expectations are exposed a discovery is serendipitous because it arises from an unexpected source of knowledge or because knowledge is produced in an unexpected way specific skills in fact are associated with serendipitous discovery but the exercise of these skills is dependent on external factors such as timeliness and community support for its success by establishing these features i provide a defense of my definition of serendipity in the fourth and final section this paper makes an explicit contribution to ongoing discussions in philosophy of science pointing to one implication of my analysis for the structure of science my understanding of how serendipity works in science grounds a normative framework that affirms the value of early publication both for individual scientists and for science itself variations of serendipity in analyses of serendipity the focus is often on the serendipitous individuals insight that an unexpected observation or event has value despite its being anomalous or even in conflict with prevailing knowledge a classic example is the narrative of the gregarious barry marshall who stubbornly persisted against the grain of prevailing wisdom to convince gastroenterologists that ulcers could be caused by bacteria this ability to perceive the potential value of an unexpected observation is frequently associated with the intellectual capacity of an individual to make some sort of connection between the observation and previously held knowledge often this is cashed out in light of louis pasteurs famous dictum that chance favours only prepared minds pp 6345 many theorists of serendipity have given a primarily cognitive account of the wisdom involved in recognizing potential value in the unexpected james austin defines what he calls the pasteur principle some special receptivity born from past experience permits you to discern a new fact or to perceive ideas in a new relationship and go on to comprehend their significance miguel piña e cunha and colleagues take up arthur koestlers term of bisociation as the functional basis for metaphorical thinking…bisociation entails an exercise of intuition the intuitive recognition of possibilities…when ideas are combined in an original way similarly mark de rond suggests that the key component of serendipity is an intellectual capability for making matching pairs of events…that are meaningfully…related other theorists have used the peircian term abduction to capture the kind of inferential reasoning that goes into evaluating the potential value of an unexpected observation 2 according to paul thagard the serendipitous moment in a scientific discovery is marked by a conceptual combination such intellectual connections are described by gary fine and james deegan as instances of analytical serendipity analytical serendipity is only one of three categories of serendipity fine and deegan identify in the autobiographical narratives of ethnographers they also identify two other categories temporal serendipity and serendipity relations temporal serendipity describes the inclusion of a dramatic but unexpected event in an ethnographers tale one that allowed the narrator to participate in aspects of a culture they would otherwise have missed altogether 3 the category of 2 of course in philosophical discussion about the logic or rationality of scientific discovery there is a deep and complicated debate concerning abduction how well abduction works as a description of the reasoning involved in some cases of serendipity is a topic i pursue elsewhere and is outside of the scope of this paper 3 this is also frequently called synchronicity in the serendipity literature following jung simultaneous occurrence of two meaningfully but not causally connected events daniel liestmans use of synchronicity as one category of serendipity in library research is picked up by several others from fields such as computerhuman interaction education and information studies synchronicity is also appealed to by organizational and management theorists however i follow lawley and tompkins who draw a distinction between synchronicity and serendipity because the former is recognized immediately whereas the latter is not serendipity relations describes the unplanned building of social networks it includes the people we meet unexpectedly who turn out to be sources of valuable knowledge or who lead to further valuable connections temporal serendipity and serendipity relations are instances in which serendipity goes beyond the cognitive connections made between people or ones being present at the right time and in the right place can just as well lead to valuable discoveries examples of serendipitous connections that are temporal or social rather than or as well as intellectual are found throughout contemporary descriptions of serendipitous science a serendipitous discovery process in science can involve multiple kinds of serendipity tales of serendipity often include the details of life that led individuals to be in the right time place and circumstances to make a discovery for instance the story of marshalls serendipitous discovery of the bacterial cause of stomach ulcers tends to focus on his role as spokesperson for his own discovery however paul thagard provides a detailed recounting of the discovery in which we see how marshalls good fortune in having the right social connections and available resources enabled him to succeed in james estes scientific autobiography the author recounts several different kinds of serendipity at times estes happened to meet the right person with whom he could continue his work some people he met guided his research in a distinct way circumstances put him in the right place and time to make key observations external events also affected the path he took as a scientist when reflecting upon these instances in his past estes sees themand consequently the scientific discoveries they enabled him to makeas serendipitous howard gest offers another example when he notes the importance of an unexpected social connection between labs in the isolation of vitamin c a former graduate student of charles king who had been working with king on the problem of scurvy wound up via a serendipitous event working in the lab of albert szentgyorgyi in hungary it was this unexpected social connection that led to the testing of szentgyorgyis sample of a chemical he had isolated and called hexuronic acid to confirm it was indeed vitamin c consequently this unexpected social connection led to szentgyorgyis receiving a nobel prize for that work in gests words svirbely the phd student had become an accidental agent connecting the research happening in otherwise isolated labs hindsight has the effect of reifying a complex process as a linear sequence of events and serendipity narratives often rhetorically trace the origin of a discovery to a magic moment in time likewise scientific processes are often only retrospectively recognized as leading to discovery thomas nickles points out that this retrospective classification of a particular series of events as leading to discovery can have a rarefying effect on our perception of the originating event what we retrospectively interpret as revolutionary breakthroughs typically begin life as rather normal work over time by telescoping historical development scientists whiggishly invest these charmed cases with far more meaning than they originally possessed…most analysts of scientific discovery fail to notice that much or most of what we count as the discovery is actually accomplished in the reworking and refinement that occurs in the years and decades following the original work as nickles notes events that follow the origin moment have as much to do with making the discovery as the moment itself in fact when a discovery narrative is told there is often a choice to be made as to which event attributes the property of serendipity to the discovery the story of penicillins discovery for instance contains multiple chance events and coincidences and the discovery was not a direct or even predictable result of alexander flemings insight in shielding the infamous petri dish from the wash 4 as gest comments regarding the narrative of the vitamin c discovery the fateful connections and sequelae involving king svirbely and szentgyorgyi were in fact quite complicated and even now difficult to sort out…a number of serendipic sic events were involved in the vitamin c story but none of them can be said to be the crucial event or accident in sum serendipity in the practice of science is more ubiquitous than momentous robert merton pointed to this first when he described what he called the serendipity pattern observing an unanticipated anomalous and strategic datum which becomes the occasion for developing a new theory or for extending an existing theory a fairly common experience i argue that it not only describes the greaterthanaveragevalue discoveries that arose with the help of chance such as penicillin but also the networks of accidental connections later recognized as valuable these include connections between ideas people places experiences and more when such connections happen during a discovery process any one of them may lead to the categorization of the discovery itself as serendipitous thus a process of serendipitous discovery is likely to involve participation from multiple scientists in one way or another and to extend across time in contrast to the individualistic depiction of serendipity as a flash of insight then we have a picture of serendipity as occurring within a community involving networks of individuals and interactions retrospectivity emergence thagard provides an excellent case study in his detailed description of one of the more popular examples of serendipity in the literature the discovery of h pylori and its relationship to ulcers for which barry marshall and robin warren were awarded a nobel prize thagard himself uses serendipity to describe two distinct events in the discovery process as a whole the observation of bacteria in the stomach and the discovery of how to cultivate the bacteria in the lab warren was not searching for bacteria in the stomach when he found it during the course of his everyday work as a pathologist as thagard comments he just happened to examine gastric specimens with sufficient microscope magnification to make bacteria visible at the time this observation was made the stomach was thought to be a sterile environment in which bacteria could not survive and so the observation was unexpected thus the discovery of h pylori bacteria in the stomach by warren was serendipitous for thagard the value of this serendipity is that it generated questions for the curious warren who then pursued investigation of the bacteria with the help of a gastroenterologist marshall serendipity here is a surprising observation that leads to a new direction of inquiry similarly serendipity played a role in marshalls later discovery of how to cultivate the bacteria in the lab attempts to cultivate it repeatedly failed at first it was then accidentally discovered that the fortyeight hours given to allow growth was insufficientthe distraction of a busy schedule and the coincidence of a fourday weekend provided the solution allowing the bacteria five days to cultivate in this case serendipity is a chance event that leads to an unexpected solution to a problem thagard separates out these serendipitymoments because they are marked by surprise and chance in contrast to the intentional phases of questioning and search that followed however as alan baumeister mike hawkins and francisco lópezmuñoz illustrate in their analysis of the history of serendipity in psychopharmacology this treatment of a single discovery process as a series of moments can be confusing for instance they consider two seemingly contradictory claims made by john cade who discovered that lithium was an effective treatment for mania cade claimed both that the discovery was unexpected and that the expected result of a clinical trial in humans was a reduction in mania baumeister and colleagues resolve this contradiction by breaking the discovery of lithium as a treatment for mania into two distinct discovery processesone serendipitous and one nonserendipitous however the observation that lithium had lethargyinducing effects on guinea pigs was not valuable until its effectiveness in treating mania was recognized until the second discovery was made the first discovery was not considered a serendipitous discovery in psychopharmacology cade himself may have thought it an interesting and valuable observation at the time but only upon confirming its value to science and medicine did it become an episode in a narrative about a discovery leading to the confusion pointed to by baumeister and colleagues as does thagard baumeister and colleagues break a process into serendipitous and nonserendipitous moments events or discoveries in order to clarify the interaction between intentional and nonintentional aspects of a discovery process however these distinctions are misleading when it comes to understanding serendipity itself in particular they prevent analysis of two key aspects of serendipity in science retrospectivity and emergence i argue rather that classifying a discovery as serendipitous points to the impact of one or more unexpected events upon a process that is not complete until the valuable outcome has been determined to understand how serendipity happens we must look at the interconnection between insight the unexpected event and the valuable outcome together not only is it often arbitrary to distinguish one unexpected connection as the crucial event as gest puts it in the quotation above but what gives meaning to the moment of surprisewhat makes it serendipitousincludes the value of the outcome as well as characteristics inherent in the moment itself consider a case of serendipity lostan unexpected insight that although wise and marked by surprise fails to result in a valuable outcome while these are hard to come byrarely does one find a publication detailing a discovery that was never made 5 one example has been described in detail by bernard barber and renée fox they tell the tale of the floppy eared rabbits an observation of a reaction in their experimental rabbit population made by two scientists at almost the same time both of whom were insightful enough to recognize it was an interesting observation that ought to be followed up only one of the scientists however actually did follow it up sufficiently to make a discovery about the effects of papain on the cellular structure of the ear cartilage there was no real difference between the two scientists original observations as barber and fox point outboth observations were unexpected and both inspired an insightful curiosity in the observers what made the difference to the discovery were the events that followed that observation and the obtainment of the valuable outcome in one case but not the other as a result dr kellner was not serendipitous in respect to this observation driven down other paths of research instead for dr thomas the serendipitous scientist in this story the planned and the unplanned the foreseen and the accidental the logical and the lucky…continued to interact beyond the original observations to keep him on the path to this particular valuable outcome thus serendipity is a category that can only be applied retrospectively to a discovery process once the valuable outcome has been determined and upon reflection on the nowapparent significance of the relevant unexpected events and insight 6 one never says this is going to be serendipitousnot only because it often occurs by chance but also because until the value of the discovery is made clear the category of serendipity does not yet apply 7 in fact empirical research shows that a period of reflection is necessary for the observer to recognize the significance of the chance event and the wisdom of her own insights in light of qualitative data acquired through interviews with academic researchers artists library users and laypeople several versions of a process model of serendipity have been developed 8 these process models all include the outcome as a necessary step in serendipitous discovery further many of them highlight its retrospectivity and the necessity of reflection upon previous events before the category is applied consider this version by stephann makri and ann blandford 5 a possible exception is alexander kohns book fortune and failure missed opportunities and chance discoveries in science however as with the example given by barber and fox the forgotten discoveries in this book are only seen as such in light of the discoveries that were actually made 6 given the quotation from nickles above one might extend this retrospectivity to many discovery processes but since it would not extend to all processes categorized as discovery processes serendipity remains a particular classification within that broader category 7 of course in some cases this timeline is collapsed such as when the value of the discovery is clear at the time of observation one example might be when a collector of fine garden gnomes happens by chance to visit a friend whose neighbor is holding a garage sale and selling a gnome whose value the collector is able to identify immediately but more often including in the examples walpole himself gives and almost always in the case of scientific discovery multiple steps are required to reveal the true value of the unexpected finding and still the gnome collector could not have known her visit to the friend would be serendipitous beforehand 8 cunha and lawley and tompkins developed the first process models through an analysis of case studies and the literature the later articles cited here refer to studies that confirmed and refined that model via empirical research because of the retrospective nature of the category the fact an unexpected event meeting or observation was serendipitous is determined by reflection upon the value of the result of a process during which that event meeting or observation played a key role first note that this process is often iterative rather than strictly linear before the value of the outcome is established several iterations of reflect upon the value project the value and exploit the connection may occur along the way other outcomes of value may be obtained and there may be several moments in which chance intersects with wisdom but the process of serendipitous discovery is not complete until a particular outcome is obtained such that it results in the perception of at least one of those moments as unexpectedly valuable in relation to that outcome only then is the mix of unexpected circumstances and insight considered an instance of serendipity second the value assigned to the moment and the outcome together is oblique in relation to the intentions that drove the underlying process forward that is the intentions behind the activity taking place at the time of the unexpected observation or event are only indirectly related to the outcome of the process the serendipitous discovery in walpoles words many excellent discoveries have been made by men who were á la chasse of something quite different this holds for cases of socalled pseudoserendipity as well the term pseudoserendipity coined by royston roberts suggests that a distinction should be made from pure serendipity in cases when the observer may have been seeking the knowledge she accidentally found one example is charles goodyears discovery of the vulcanization of rubber the actual discovery was accidentalgoodyear had not planned to heat the rubber compound he was working with when it came into contact with a hot stove however he was in general looking for a method to enable rubber to withstand the cold and such a method was revealed by his mistake because goodyear was looking for just such a solution but found it in an unexpected place roberts feels this example does not capture the essence of serendipity however the outcome is still obliquely related to the intentions driving the processthe intentions behind goodyears use of the stove at the time did not include a hypothesis about vulcanization the value of heating rubber was unknown at the time the rubber was spilled and so was determinable only retrospectively once the effects were observed and their application surmised similarly as aharon kantorovich argues in his booklength treatment of serendipity in science processes of discovery frequently end in a way unpredictable from the perspective of their origins because other scientists will take an observation and work with it new purposes and new knowledge inevitably arise that do not reflect the intentions of the original observer in making and disseminating the observation itself the observer in kantorovichs words remains blind to the ultimate value of the observation it is this oblique relationship with the intentions driving the underlying processthe reasons behind the actions being taken at the timethat marks serendipitous discovery the outcome indeed emerges from the processes and intentions at hand for instance take the origin of the word itself in the fairy tale that walpole recounted in his 1754 letter to more the princes of serendip were on the road to persia when they made observations that later when they encountered a person with a problem became useful in solving that very problem at the time of making the observations the princes could not have known they would encounter the camel driver who needed that knowledge nonetheless they recognized their observations were interesting and potentially valuable and readily recalled them when they could be used a collaboration between them and the camel driver thus emerged when he presented them with a problem to which they had the solution an emergent property can be described as novel in the sense that it cannot be reduced to the properties that exist in the underlying process or context from which it arose a popular example is the idea that consciousness emerges from the neural networks of the brain in the tale of the princes of serendip the property of serendipity emerges from the interaction of the princes observations with the further context of the camel drivers problem and not from any properties inherent in the observations themselves9 as david chalmers points out however emergence is used in science and philosophy to express two distinct concepts what is often called weak emergence is defined epistemologically as the result of a limitation in our understanding of events objects and their properties in contrast strong emergence suggests that the emergent phenomenon cannot be deduced even in principle from the properties of the underlying context or process from which it arises considering serendipity in light of this debate draws out both why the term applies to serendipity as well as the nature of the role epistemic expectations play in serendipitous discovery one might consider serendipity as an example of weak emergence because it seems that only our epistemic limitations make it unexpected however even if it were possible to rationally reconstruct the process involved in some past incident of serendipity perfectly thereby enabling us to explain how that event occurred this does not mean it is not a case of strong emergence further both the state of knowledge in science and the environment in which it is practiced continues to change and so the complex interaction of factors that enables a serendipitous discovery to occur in one instance will not be repeated in the next the ability to explain a causal process when looking backwards does not logically entail that we could in turn predict that event when looking forward10 each case of serendipity arises because of epistemological limitations but these limitations are part of the very nature of serendipity itselfserendipity occurs precisely when there is a failure to expect that a particular process will produce the valuable outcome it does thus there are reasons to see serendipity as a case of strong emergence i do not have the space here to fully explore whether serendipity is a case of weak or strong emergence but wish to highlight the role of epistemic expectations by raising the question that is there is an intimate interaction in instances of serendipitous discovery between epistemic expectationsabout where knowledge might come from or predictions about what will happen nextand the impact of retrospectively recognizing serendipity upon those expectations serendipity in challenging such expectations changes them thagard argues that surprise is an emotional input to the questioning process that makes abduction both possible and useful we are led by our surprise to reason about possible explanations for anomalies for example an important aspect of the sagacity or wisdom involved in serendipity is this perception of potential value leading an observer to attend to an unexpected observation rather than simply dismissing it as fleming did with his moldy petri dish we look more closely because something has surprised us and roused our curiosity the surprise that accompanies serendipity is not always the sudden and shocking kind of surprise that we experience when a jackinthebox springs forth however in many cases it is more of what some call an ahaexperiencethe psychological experience of having a new idea about how things connect or seeing something in a new light or with a new sense of appreciation in all cases however the experience is of ones own expectations being overturned surprise and epistemic expectations while surprise and other emotional or aha responses to a shift in our expectations operate on the level of the individual the expectations themselves derive both from personal experience and importantly from the norms of our community the relevant norms have to do with how knowledge is expected to be produced or are about who is expected to produce or contribute knowledge for example further the role of expectations extends beyond creating the conditions for a moment of surprise serendipitous individuals encounter the unexpected see it as potentially valuable and thereby are open to sources of knowledge in the world that exceed their own expectations they must also be willing to change those expectations upon reflection because serendipity is more than cognitive but also includes unexpected outcomes from the formation of new relationships or ones presence at certain times in certain places the relevant expectations go further than those about what kinds of knowledge can be gained or even what methods might produce knowledge new sources of knowledge can be unexpected results from experiments but they can also be people from social or epistemic communities or new experiences that were not previously thought to be potential sources of knowledge cunha and colleagues introduce a concept useful here the idea of generative doubt they analyse the case of honda a company often deemed serendipitous for its cornering of the north american market with their super cub motorcycles in the mid1960s the rapid rise to power of honda in america has been explained by appeal to two separate narratives in one honda is said to have planned well and accommodated new opportunities by being prepared in the other honda is described as flexible and highly responsive to the changing circumstances as they unfolded cunha and colleagues suggest that a successful serendipitous company moves between these strategic approaches via generative doubt generative doubt is the motivated search for understanding stimulated by the experience of not knowing as cunha and colleagues demonstrate this can be practiced on the community level as well as by individuals in the case of honda the company indeed had a plan for marketing in the united states but they were able to adapt to a new source of valuable information when it arose honda intended to directly compete with other popular manufacturers at the time yamaha and harley davidson but were having a difficult time finding a place in that market then their salesmen in california reported that people were asking them a lot of questions about the super cub the small and lightweight motorcycles they themselves were using and honda changed its overall strategy they then had huge success with their new ad campaign slogan you meet the nicest people on a honda opening a new market of motorcycle drivers in the language of organizational management and as cunha and colleagues interpret honda was able to use its centralized resources for manufacturing to adapt with a bottomup strategy of taking up a suggestion from an unexpected source the willingness to change expectations is something that can be learned chris napolitano argues that intentional…serendipitous actions lead to serendipitous relations in the life of an individual these intentional actions include cultivating an open attitude to unexpected events as opportunities and refining the skills needed to take advantage of such opportunities when they arise as people do not always realize the value of an event at the time it occurs but rather upon reflection and in light of its positive outcome these skills are generalizable and adaptable rather than specific reactions to certain kinds of events similarly estes notes that a scientist will not always be able to predict the trajectory of her own research career as unexpected meetings events and observations will change its direction over time thus in order to maximize potentially serendipitous moments along the way ones expectations about the end result of ones intentions must remain incomplete this involves not only preparedness but also the intentional development of ones ability to adapt to unexpected situations when they arise as napolitano suggests simply recognizing an unusual event as being potentially gainsladen is not enough an individual must seize the opportunities that they identify in that unexpected event action must be taken to follow up on the insight that an unexpected event has potential value the skills needed to take such action can be intentionally developed and honed both openness to ones intentions leading to an unexpected outcome and the ability to adapt to and act upon opportunities for reevaluating ones own expectations about the outcome of a process are the types of skills relevant for serendipity there are skills involved in cultivating ones ability to recognize potential value in the unexpected as well fine and deegan point to this when they suggest that being present for an event in cases of temporal serendipity is not likely to be random ethnographers rather have a sense about when a major cultural event is likely to take place and where even though events are unpredictable types of events tend to occur regularly at particular times…and we depend on this patterned quality of events to permit us to make temporal choices about when to observe those who manage to hone such skills are called superencounterers by sanda erdelez erdelez studies information encounteringthe accidental discovery of useful or interesting informationas a distinct aspect of human information behaviour the superencounterers she interviewed not only feel their research benefits from frequent accidental discoveries of information but also see themselves as acting in ways that encourage such beneficial encounters they believed in creating situations conducive to encountering thus individuals can develop skills that benefit them both before and after they encounter something unexpected thereby actively enabling serendipitous discovery however as in the case of the floppyeared rabbits conditions beyond the intentions or skills of the individual may act as a constraint on serendipitous discovery barber and fox describe several factors that can interfere limited laboratory resources preconceptions about what kinds of discoveries are possible a greater interest in an alternative research direction and time constraints abigail mcbirnie observes that the researchers and jazz musicians she interviews often recognize potential value in an unexpected encounter and yet fail to follow up on that recognition to make a discovery this is due to what she calls serendipity filters or pressures including time need responsibility and environment people susceptible to such filters may have a hard time turning toward the value they perceive because they feel they cannot turn away from the work they are already engaged with lori mccaypeet suggests there are both internal and external precipitating conditions that affect an individuals ability and inclination to become aware of respond to and follow up on a potentially serendipitous experiencethese conditions thereby ultimately impact the outcome conditions include the physical and social context in which the experience occurs as well as the more general context in which the individual works and lives the internal conditions mccaypeet lists are misleading preconceptions divergent behavior and feelings of frustration while these are examples of individual actions and personal characteristics they are also the kinds of actions and characteristics that are strongly influenced by external conditions such as community attitudes and institutional organization thus individuals can and do manipulate conditions so that unexpected encounters with new information will more likely occur individuals can also exercise some control over whether they recognize and follow up on valuable unexpected encounters however the efforts of individuals are also constrained by context so on the level of the individual serendipity is often seen as paradoxical requiring both luck and skill mcbirnie calls this the paradox of control she argues that the process aspect of serendipity is beyond the control of the individual highlighting that complex processes are often unpredictable the perception of serendipity and its results however are more susceptible to control the skills involved in such perception and in ones ability to be adaptive to changing circumstances can be developed but as just noted the environment in which the individual is perceiving and acting may be such that her skills are constrained and she cannot follow up despite recognizing the potential value in the unexpected so one must be lucky not only in terms of encountering the unexpected but also in terms of having the opportunity to put ones skills to use and succeed in making a discovery the work the category of serendipity does is to differentiate such discoveries from the merely lucky credit is due for the insight that accompanies surprise rachel mckinnon offers some insight into the relationship between luck and due credit in her analysis of the phrase you make your own luck mckinnon argues that while it is not technically possible to develop skills that directly increase the luck one experiences it is possible to develop skills that keep one in the game longer and thereby increase the overall probability that one will be lucky superencounterers and other serendipitous individuals seem to have the necessary skills to keep themselves in the game long enough to encounter the unexpected more often to recognize its potential value and then to follow it up again beyond having the required skills and therefore deserving credit for their role in the discovery process they must also be in the right time and placein the right gamefor the utilization of those skills to lead to success some have argued for instance that flemings involvement in the discovery of penicillin has more to do with his role in the scientific community than with the actual insight he displayed in observing p notatum in his petri dish 11 he would not have played a role in the particular process that led to the valuable outcome despite his observation if he had not also been an active lab director and educator in the community at the time 12 in the following section i look at what kind of scientific community is more likely to encourage rather than constrain the efforts of individuals to play a role in a serendipitous discovery implications for the norms and practice of science some have argued that the democratization of knowledge production through recent developments in communications technology for instance increases the likelihood of serendipitous discovery increasingly diverse groups become involved in science and other intellectual enterprises exposing each other to new sources of knowledge and new ways of knowing others have argued that serendipity occurs most often when individual scientists have free reign to follow their research in any chosen direction in turn some have argued that serendipity can be suppressed in a hierarchical system toby sommer calls attention to this by coining the term bahramdipity bahram is the persian king in the fairy tale who attempts to foil the princes of serendips efforts to reap the benefits of their wise observations in science bahramdipity describes instances of failing to give credit to individuals who would have played a role in the discovery process sommers examples are of scientists whose potential discoveries are elided or neglected by those higher up in the hierarchy of the scientific community one famous example is that of selman waksman and his graduate student albert schatz schatz claimed to have brought the importance of streptomycin as an antibiotic to waksmans attention and to have done much of the necessary work but waksman was credited with the discovery and received the nobel 11 most notably fleming himself who humbly declared during his nobel prize award speech that my only merit is that i did not neglect the observation and that i pursued the subject as a bacteriologist 12 i am far from alone in pointing out for instance that others had made similar observations but had lacked the timeliness and social connections that fleming had a fairly wellknown example is the french graduate student ernest duchesne whose dissertation reporting on the therapeutic effects of another penicillium mold was submitted in 1897 duchesnes work remained unknown and he died a few years later however and so his preliminary efforts were not taken up to be part of the discovery process that ultimately led to penicillin prize a recent study also shows that bottomup management of research in science leads to a greater number of serendipitous discoveries the suggestion then is that undirected egalitarian communities of independent scientists are more likely to generate serendipitous discoveries than communities with leaders and specific goals however this suggestion raises the following question if each scientist works in isolation toward their own desired ends how does science itself fare as a consequence for one contemporary science is complex both in terms of theory and toolshow can any one scientist have the necessary knowledge and resources to achieve progress without the help of others13 also if the goals of these individualized scientists are for personal profit how can we ensure the practice of science generates knowledge valuable to society as a whole these questions have been taken up by an ongoing discussion in philosophy of science regarding the possible conflict between the priority rule in sciencethat the first scientists to complete a discovery process get all the credit for that discoveryand the imperative to share knowledge in the interest of scientific progress overall 14 it seems that if a scientist or group seeks credit for a discovery they have an interest in keeping their knowledge to themselves until the discovery process is complete this however prevents other scientists from accessing the knowledge being produced by that process until the discovery is made i argue that because this delay not only affects the time it may take for the discovery to be made by decreasing the likelihood of cooperation for example it also affects the potential for serendipitous discovery consequently there is an additional personal reason for an individual scientist to want to share her knowledge because it improves her chances overall of playing a role in the completion of a discovery process recent work on this has been an effort to reconcile a scientists personal desire for garnering credit for making a discovery with what merton called the communist norm of science michael strevens argues that the priority rule plays an important part in science as an incentive for individual scientists to work toward potentially valuable discoveries they desire the prestige that making a discovery will grant them and so through the work of individual ambitious scientists science benefits overall from their discoveries despite the role of competition between scientists and groups however both strevens and remco heesen provide arguments for why it nevertheless benefits individual scientists to subscribe to a communist approach to science or total sharing of information i suggest that a similar argument can be made from serendipity to return to the features of serendipity described above i have argued that it emerges unpredicted from the processes of scientific practice and communication thus no one scientist can say ahead of time that she will play a role in a serendipitous discovery process let alone in its completion epistemic expectations determine when serendipity will occur by defining what counts as unexpected insofar as epistemic expectations are overturned by serendipity the occurrence of serendipity will alter the future expectations of individual scientists and potentially of the community of scientists as a whole from the perspective of an individual scientist she may be blind to the ultimate value of some of what she publishes 15 a contribution she makes to science by publishing her intermediate results for instance may unexpectedly result in her involvement in another discovery process on the other hand some other scientist may publish his intermediate results and thereby unexpectedly contribute to a discovery process she will gain the prestige for having completed the information produced along the way to one discovery that is may contribute to other research outcomes in ways not predicted by the scientists involved in that underlying discovery process serendipitously the potential for the publication of intermediate results to benefit both science and the individual scientist has been argued for by thomas boyer he points to a distinction between community norms that allow an individual to benefit from the publication of intermediate results and norms that do not specifically in a community in which publishing the end result of a discovery process receives far more credit than publishing an intermediate result the individual lacks incentive to publish early boyer suggests that if a community wanted to encourage early publications it could be better to acknowledge the value of preliminary and intermediate steps instead of emphasizing only the achievement of the last step if preliminary and intermediate steps were more widely acknowledged as being essential for serendipitous discovery i suggest they would have higher value this goes hand in hand with widening the scope of credit due for enabling scientific discovery to include unexpected sources of valuable knowledge as an example take the discussion concerning the role that rosalind franklin played in the discovery of the structure of dna as james watson tells it in his autobiographical account the process of this discovery was marked by serendipity one instance of which was the happening upon franklins crystallographic images which inspired watson and francis crick to think in terms of a helix a footnote in the original nature publication of the model watson and crick came up with thanked franklin for stimulating them with a general knowledge of her research results thus from one perspective watsons encounter with franklin was fortunate happenstance and he was lucky to have gained the knowledge he needed from an unexpected resource from another perspective franklin contributed to the process of discovery as a fellow scientist the perception of a discovery as serendipitous points to the recognition that it was enabled by something unexpected when our expectations shift however for example from thinking watson was wise in seeing the worth of franklins work to thinking franklin was deserving of credit for her contribution to the discovery our perception of the nature of the serendipity involved also shifts rather than being wise for recognizing the value of an accidental finding watson was fortunate to have made a particular social connection and to benefit from anothers work since watsons autobiographical account was published it has become common to suggest that what led watson to see his access to franklins research as serendipitous reflected a mistaken expectation about her ability to contribute to his scientific discovery process whether or not this interpretation is correct it reflects a general belief that such expectations have changed over time 16perhaps paradoxically a scientific community whose members are more likely to take advantage of opportunities for serendipitous discovery is also more likely to recognize the control it can exercise over who is perceived as a possible source of new knowledge consider as a counterexample kantorovichs naturalistic depiction of serendipity in science the observation of an anomaly reasoning about its potential value for scientific knowledge and the acceptance of this observation as potentially valuable by the broader scientific community are as kantorovich argues processes guided by epistemic norms scientists do not take the time to attend to an unusual observation nor do they take up such an observation into processes of investigation and inquiry unless they believe it has epistemic worth and epistemic worth is determined according to the norms of scientific knowledge but kantorovich argues that this process operates fully at the group level in the form of a collective brain and is therefore as unintentional as evolution itself however because the scientific community is made up of individual members it is not the scientific community in the abstract but rather individual scientists whose actions and behaviour maintain the norms of their community as i suggested in the previous section some control may be exercised over serendipity by the individual insofar as she can cultivate the associated skills serendipityrelated skills may also be cultivated by a community that for instance utilizes generative doubt as honda did in the example given by cunha and colleagues and above generative doubt in relation to the norms of epistemic expectations would require an approach somewhat like the following a scientific community that has developed appropriate epistemic norms about what kinds of methods and observations for example can be expected to produce scientific knowledge may also be skilled in adapting those norms when surprising events call those expectations into question in contrast to an organism that evolves through mutations and natural selection then a serendipitous scientific community is a group that can intend to learn from their experience with the unexpected further such a community will be more adaptive to the broader needs of society when problems arise the cultivation of adaptive skills and the ability to take up the work of others quickly into a discovery process can result in more timely and effective responses to those problems in sum a community that learns to expect the unexpected might also readily acknowledge the potential value of preliminary and intermediate results alongside the value of competition and the priority rule that is serendipity does not exist without the underlying process in relation to which its outcome is oblique but the expectations that ground the intentions that drive that process in a selfreflecting community will themselves shift as the community learns about the limits of its own expectations therefore serendipity will continue to be a relevant category for describing discoveries insofar as what expected is a shifting ground 17 in a scientific community with serendipitybased norms such as one that adopts generative doubt toward its own epistemic norms individual scientists will continue to have the same chances of being serendipitously involved in the completion of a discovery process in this way awareness of the potential for serendipity results in a democratization of knowledgeproduction by widening the scope of expectations about potential discussion for determining franklins role and offers a complementary approach to the discovery in her article reassessing discovery 17 one can assume there will always be unexpected observations or events so long as scientists fall short of omniscience sources of knowledge without also resulting in the wholesale individualization of the pursuit of discovery as a final point i return to the problem of whether this kind of community encourages individuals to exercise the relevant skills and to play a role in serendipitous discovery i argue that it does in the same way that it improves the economy of research that is as thagard points out contexts in which experiments can be done without high costs to the overall research programmerequiring too much time attention or material resourcesare conducive to serendipity this may be for example because experiments can be done that initially seem unnecessary or unimportant but that can sometimes result in the accidental discovery of valuable knowledge such was the case in patrick lees path to discovery of the potential value of the reovirus for cancer research he allowed one of his graduate students to conduct an experiment that lee assumed would reveal nothing interesting but which had a surprising result further because it was economical to repeat the experiment hypotheses of error and coincidence could be ruled out to conclude that indeed an interesting anomalous result had been obtained 18 serendipity does not occur as a result of blindly stumbling on important phenomena or through simple trial and error but rather during the course of normal scientific work the more scientific work that can be done the more likely a discovery might occurthere is both an increase in opportunities for chance observations and an increased possibility that such observations will be followed up the early publication of results as boyer alludes improves the economy of research by preventing the unnecessary repetition of discoveryrelated work likewise a community in which knowledge is regularly shared decreases the burden on its individual members for doing that work by improving the chances they will come across results that are useful it thereby also improves the chances that an individual scientists efforts will result in a discovery by making it more possible that her published results will be taken up by someone else individualized constraints such as pressures on time resources and attention are thereby mitigated by ones role as a node in the greater network of science in this way scientists are kept in the game longer when they publish more results of their research and consequently there is a higher probability that the exercise of their skills will lead to them playing a role in a serendipitous discovery process conclusion this paper has sought to define serendipity as it exists in the practice of science to delineate its key features and to illustrate how taking serendipity seriously grounds specific normative frameworks and approaches to publication practices i have argued that serendipity is an emergent property of scientific discoveries describing an oblique relationship between the outcome of a discovery process and the intentions that drove it forward further the conditions that generate one instance of serendipity are also thereby changed by it serendipity is often conceived of as a flash of insight or a eureka moment triggered by an unexpected observation or event i have shown that particularly in the context of scientific practice and scientific discovery serendipity can be complex a serendipitous discovery process may involve several unexpected observations and events and may entail the formation of a network of interactions between individuals from various communities backgrounds and even times therefore serendipity in science is better seen as a process that occurs within the scientific community if we are to understand how it emerges from scientific practice i argue that the most important aspect of serendipity is its role in disrupting and changing epistemic expectations in particular about the kinds of discoveries that might be made and where they may originate science has specific epistemic norms about the methods and types of observations likely to produce knowledge further scientists have expectations about who might have the knowledge they need when a discovery is retrospectively categorized as serendipitous it is because somewhere along the process of that discovery an unexpected event observation or source of knowledge led to an unimagined outcome because individuals and even communities can cultivate skills that allow them both to perceive the potential value in the unexpected more readily and to adapt and act to follow up on that value serendipity can to a degree be controlled this is paradoxical on the individual level insofar as the individual cannot control the rest of serendipity rather environmental and even internalized constraints that reflect the norms and resources of their community and context can prevent individuals from utilizing the skills they have thus serendipity requires both luck and skill it is not paradoxical when we look to the level of the scientific community as the space in which serendipitous processes of discovery occur that is some community norms and practices can circumvent the paradox through mitigation for instance communities that share information readily not only create opportunities for unexpected discoveries to occur sharing information also improves the economy of research overall meaning that more scientists can share the work to be done on any particular discovery process consequently opportunities for utilizing the relevant skills of perception and adaptation will both be more frequent and more effective from the perspective of individuals in conclusion if we acknowledge both the prevalence and importance of serendipity to the practice of science and want to encourage it more needs to be done than ensuring different kinds of scientists casually meet up at the lab water cooler the role of epistemic expectations needs to be taken seriously and each member of the scientific community ought to participate both in exposing the limitations of those expectations and by contributing knowledge to the broader network while further recommendations could be made i have here argued that at least one aspect of a scientific community the regular sharing of knowledge so that it can be taken up by other scientists will encourage serendipitous discovery and insightful questions two anonymous reviewers provided thoughtful advice on how to improve upon previous versions any errors that remain are my own

in this paper i argue for understanding serendipity in science as an emergent property of scientific discovery describing an oblique relationship between the outcome of a discovery process and the intentions that drove it forward the recognition of serendipity is correlated with an acknowledgment of the limits of expectations about potential sources of knowledge i provide an analysis of serendipity in science as a defense of this definition and its implications drawing from theoretical and empirical research on experiences of serendipity as they occur in science and elsewhere i focus on three interrelated features of serendipity in science first there are variations of serendipity the process of serendipitous discovery can be complex second a valuable outcome must be obtained before reflection upon the significance of the unexpected observation or event in respect to that outcome can take place therefore serendipity is retrospectively categorized third the primacy of epistemic expectations is elucidated finally i place this analysis within discussions in philosophy of science regarding the impact of interpersonal competition upon the number and significance of scientific discoveries thus the analysis of serendipity offered in this paper contributes to discussions about the socialepistemological aspects of scientific discovery and has normative implications for the structure of epistemically effective scientific communities

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resumen el extraordinario crecimiento de ciertas poblaciones de ungulados es cada vez más preocupante en las áreas agroforestales ya que la sobreabundancia puede afectar negativamente al ambiente natural y el sustento humano sin embargo la sociedad puede percibir negativamente el exterminio de fauna para reducir sus números y mitigar el daño usamos una encuesta en línea que incluía un experimento de elección para determinar las preferencias de los ciudadanos españoles por las medidas de control poblacional relacionadas con los efectos negativos de la sobreabundancia de ungulados en dos parques nacionales agroforestales de españa usamos la clase latente y la disposición para pagar dentro modelos espaciales para analizar los resultados de la encuesta el 2 de los respondientes creyó que un parque nacional no debería tener intervención humana incluso si la falta de manejo pudiera causar una degradación ambiental mientras tanto el 95 de los respondientes estuvieron a favor de los esfuerzos para reducir el daño causado por la sobreabundancia de ungulados cuando los efectos sustentables sobre el ambiente de la sobreabundancia de venados se convertían en efectos insostenibles los estimamos como pérdidas de bienestar humano para los respondientes de la encuesta cuando los efectos sustentables transitaron hacia la nula visibilidad de efectos los estimamos como ganancias de bienestar descubrimos que el tipo de programa de control de fauna era un tema muy relevante para los respondientes el control indirecto en el que se evita el exterminio fue la acción preferida por los respondientes el 66 de los respondientes estuvo de acuerdo con la opción de que los cazadores paguen por sacrificar animales para reducir el impacto de los ungulados en lugar de que el costo del manejo provenga de los impuestos mientras que el 19 de los respondientes estuvo en contra de esta opción y dispuesto a pagar por otras soluciones en los parques nacionales nuestros resultados sugieren que el exterminio de vida silvestre en los parques nacionales podría ser una herramienta socialmente aceptable para manejar problemas de sobreabundancia en ciertos contextos pero también podría generar algunos conflictos sociales palabras clave cacería conflicto experimento de elección sobreabundancia retorno a la vida silvestre ungulados introduction in most developed countries there is a growing demand for natural landscapes and a desire to let areas undergo natural succession however nonintervention could produce environmental degradation in certain cases for example seminatural habitats traditionally maintained by anthropogenic activities such as grazing or extensive agriculture harbor a high diversity of animals and plants and a lack of active management may be ecologically less favorable for some species this has led to an increasing scientific debate between conservation scientists who believe natural processes should be allowed to take their course without human intervention and those who advocate for managing nature actively some of the general public also thinks there should be no intervention and the debate about when and where to carry out interventions to maintain reduce or enhance wildlife populations has been heated at times this debate may be particularly contentious in relation to national parks these areas are meant to be a reflection of wilderness but management of certain ecological situations may be needed particularly when habitat protected by national parks is already created or maintained through human activities or when national parks are relatively small and thus largely influenced by activities outside them as happens frequently in europe management objectives of protected areas are usually based on scientific information about the ecology of the system and the efficiency of different management tools however there is a need to assess how people perceive management of protected areas because social preferences may influence the management tools chosen to attain certain objectives and their success an extreme case of valuable ecosystems that could be compromised by a nonintervention model is national parks in agroforestry systems in many agroforestry systems in europe and north america the expansion of forests as a consequence of land abandonment intensification of certain hunting management practices and a lack of large predators has resulted in a tremendous increase in ungulate numbers these increases are related to a number of negative impacts on ecosystems and human livelihoods including detrimental effects on vegetation and other fauna disease transmission to livestock traffic accidents and damage to crops models predict that the number and extent of favorable areas for ungulates will increase in the next decades suggesting that their distribution and abundance and the damage they cause could increase there is growing concern about overabundant ungulate populations in europe and north america reducing ungulate numbers and mitigating their damage can be done multiple ways such as culling translocation contraception introduction of large carnivores fencing to prevent vegetation browsing vaccination to prevent disease transmission management of food and water points to prevent contact between wild and domestic animals etc the application and success of different management tools depend on many ecological and human factors among other things acceptance of the techniques employed and collaboration between stakeholders involved are important several societies have a negative perception of different wildlife population management tools lethal control may be one of the most effective tools to mitigate wildlife damage although consequences are not always certain nowadays there is a growing repudiation of it which may be influenced by mass media campaigns against it acceptance may depend on damage or threat levels on the species involved and on the goal of the intervention which all in turn have ethical and emotional underpinnings most knowledge about peoples attitudes toward wildlife management that takes into account the perceived level of damage has been generated in studies that considered direct impacts on human livelihoods or safety much less information is available on attitudes toward wildlife management linked to ecosystem effects it is essential to assess not only peoples acceptance of different management methods but also how this relates to the economic costs associated with the use of alternative management tools however the use of environmental economics to quantify societal preferences is rarely considered it is particularly interesting to address these points in relation to national parks because societal acceptance of human interventions in these areas may differ from acceptance of interventions in other areas less valued from a conservation perspective assessing the balance between sensitivities related to nonintervention nonlethal control and lethal control used to minimize ungulate damage in agroforestry protected areas may inform and contribute to rethinking the concept of pristineness and wilderness management dilemmas in these areas of high conservation value it might also contribute to the debate around the use of recreational hunting to provide funding for conservation we sought to improve knowledge of the societal acceptance of different management tools to control overabundant populations of ungulates in national parks in southern europe we used environmental economics tools based on individual stated preferences to analyze the tradeoffs between environmental and human costs of overabundance and management tools this approach allowed us to estimate the change in wellbeing associated with different scenarios and to consider societal preferences related to lethal and nonlethal wildlife control methods study area the spanish cabañeros and monfragüe national parks established in 1995 and 2007 respectively are representative of mediterranean agroforestry areas these parks are 408 and 184 km 2 respectively the main objectives of spanish national parks are to ensure the conservation of their natural and cultural values according to the spanish legislation national parks are places where natural processes are a priority although proactive management may become necessary to preserve ecological equilibrium the red deer is a hallmark of these parks large predators that may prey on ungulates do not occur in the study area red deer densities in both parks are 1530 individualskm 2 such high deer numbers are associated with significant damage to vegetation high disease prevalence and the displacement of other wildlife species in similar ecosystems also large densities of ungulates lead to increased physical contact between wildlife and livestock resulting in increased disease transmission risk traffic accidents and crop damage are also cited among the effects of overabundant ungulate populations although there are fewer such problems in the study areas because crops inside the parks do not have a production aim and traffic is limited further description of the effects conservation biology volume 00 no 0 2020 of deer overabundance in the study areas is in supporting information in the studied national parks deer densities and their impacts are considered sufficiently high by park managers to warrant regular ungulate management to reduce damage actions are usually live trapping of deer and subsequent transportation of trapped animals to a private hunting ground or a slaughterhouse culling and other indirect measures to mitigate ungulate impacts such as fences for the protection of vegetation and ungulate vaccination are also used recreational hunting is not allowed in spanish national parks data an online survey was conducted in february 2018 on the web platform we used a stratified consumer panel and identified 190 people representative of spanish society relative to rural and urban populations age and gender respondents had to be ࣙ18 years old the online questionnaire included several initial questions on knowledge of and experience with spanish national parks the questionnaire also dealt with respondents a priori perceptions of the effects of overabundant ungulates on ecosystems and human livelihoods and current ungulate management tools in spanish national parks the questionnaire included 12 choice cards after responding to the choice cards respondents chose their preferred deermanagement program taking into account that the cost of the program varied depending on the chosen level of management the costs reflected the average marginal willingness to pay estimated in a pilot phase of the questionnaire once they selected their preferred management program respondents were referred to a scenario in which recreational hunters cover the cost of the preferred program rather than the cost being covered by tax payments choice modeling choice modeling includes a set of economic valuation methods based on stated individual preferences respondents choose or rank several scenarios that present different combinations of conservation biology volume 00 no 0 2020 levels of the attributes related to the subject matter these combinations are the result of an experimental design based on defficient criteria and were produced with ngene software several pretests of the questionnaire were performed including 2 pilot surveys with 39 and 35 individuals respectively pilot surveys were conducted to get the priors for the experimental design we examined the social preferences of respondents for different management tools employed in relation to the level of effects of red deer overabundance on vegetation and other wildlife species and the level of risk of infection to livestock effects were categorized as damage not visible damage visible but the system is sustainable and damage visible and the system is unsustainable in the cards presented to the respondents the terms sustainable and unsustainable were not used rather we used specific terms to describe each category for sustainable we mentioned only that damage was visible for unsustainable we used for example there are problems with the growth of some plants and some species are missing from the park a nomanagement alternative was presented as a no program scenario in this context lack of a program to control deer overabundance would have negative effects on these 2 national parks a detailed description of selected attributes and their respective levels are disaggregated in fig 2 individuals chose their most preferred and least preferred programs and a full ranking was obtained figure 3 shows an example of choice cards a respondents choice among the scenarios presented on each card represented their idea of tradeoffs among management tools environmental impacts and the price attribute this let us estimate their wtp for each of the management tools relative to the different levels of environmental impacts we used the most preferred choices in a wtpinspace model to estimate respondents preferences the model was run with the software nlogit version 60 we assumed normally distributed random parameters we also used a latent class model with random parameters to analyze heterogeneity among respondents with latent gold version 51 software results respondents included 95 men and 95 women and their average age was 47 years most had visited a national park in spain at least once monfragüe and cabañeros were in the tenth and twelfth visitation positions respectively among the 15 spanish national parks seventy percent of the respondents were willing to visit a national park in the following year monfragüe and cabañeros were chosen for a visit 12 of the time more than 90 of respondents expressed their a priori opinion about the effects of overabundant ungulates on ecosystems and livelihoods whereas few selected the notsure option on a scale of 15 respondents thought that the more negative impacts of ungulate overabundance were road accidents crop damage and vegetation damage the rest of the analyzed attributes were perceived as being less affected by an overabundance of deer among the set of management tools to deal with deer overabundance in national parks respondents were only in a priori agreement with use of indirect measures to mitigate ungulate damage respondents were indifferent to other management options approximately onethird of the participants were a priori against the use of lethal control of deer in national parks and 52 of them did not change their position in extreme cases such as overabundant deer increasing the risk of lethal traffic accidents damaging protected animals and plant species or threatening the red deer population choice modeling showed that most respondents had positive preferences toward managing deer overabundance all the attributes coefficients were statistically significant at the 95 level and the signs of the effects were as expected human wellbeing was subject to losses as sustainable effects transitioned to unsustainable effects and to gains as effects transitioned to no visible effects coefficients were higher for unsustainable effects than for sustainable effects indicating stronger wellbeing losses in the former case respondents thought the unsustainable impact of deer overabundance on livestock was the most important effect to avoid followed by unsustainable effects of overabundant deer on wildlife and on vegetation however comparisons of wtp for the nodamage options showed that the largest gain in wellbeing was on no damage to vegetation followed by no damage to wildlife and no damage to livestock precisely the opposite order of effects indirect measures were on average the preferred management tool followed by live trapping only 2 of respondents always chose no intervention in the choice experiment and thus thought a national park should follow its course without human intervention these respondents explicitly expressed their reasoning in answers to a followup question and were willing to accept the environmental degradation of these biodiversityrich areas that would result from no intervention results of the wtp in space model showed high heterogeneity among respondents and the lcm identified 3 different classes of behavior we found that 445 of respondents attached more importance to unsustainable effects than to management tools the vegetation interventionists were significantly influenced by the tools to be employed impacts of overabundant deer on vegetation and unsustainable livestock damage wildlife interventionists were 137 of the sample and their wtp was mainly explained by management tools to be employed wildlife effects of deer overabundance and unsustainable livestock damage a comparison of wtp values in the wtp in space and lcms is in supporting information sixtysix percent of respondents agreed to selling permits to hunters to cull deer so they could avoid paying additional costs to control overabundant deer in this way additional funds would be raised without additional monetary efforts for the citizens nineteen percent of respondents were willing to implement a management program to mitigate the impact of overabundant species but were absolutely against this being done by recreational hunters in national parks discussion perception of lack of management in most developed countries the vision of management and conservation of natural resources has shifted from a conservation biology volume 00 no 0 2020 utilitarian view to a more mutualistic vision where nature and society affect each other in this context it is important to investigate societal attitudes toward natural and human disturbance in protected areas such as national parks the majority of our respondents agreed with the implementation of a program to manage overabundance of deer in spanish national parks rather than holding a view of parks as pristine landscapes where no management actions should be taken this contributes to the unsettled dilemma about human intervention versus letting nature take its course in protected areas and indicates a general perception that human activities are an essential component of agroforestry habitats and their maintenance in other words spanish society seems to believe these 2 biodiversity hotspots are the result of longterm human activities and that preserving the ecological equilibrium there may require proactive management tradeoffs between environmental costs of overabundance and management tools our results showed that in general management tools used in the overabundancemanagement program affected respondents social wellbeing more than the environmental impacts of overabundant deer indicating that the way to manage conservation biology volume 00 no 0 2020 deer numbers in these 2 national parks is the main source of potential conflict to be considered by policy makers however decisions of individuals from class 1 were more influenced by whether environmental costs of deer overabundance were unsustainable than by the management tools employed our results illustrate the sensitivities of society to ungulate lethal and nonlethal management in protected areas where recreational shooting is usually much maligned nonlethal management of overabundant deer impacts was the preferred action the secondmost preferred action was live trapping of deer direct culling was the least preferred method to control deer overabundance these results are consistent with current management in these 2 national parks and previous findings in the scientific literature and are explained by moral and philosophical considerations discussed by manfredo et al fischer et al and brock respondents perceived that the consequences of the management tool mattered but they also often viewed killing animals as something to be avoided and perceived that the context of the killing was relevant in any case a large part of the respondents did not reject use of lethal control of wildlife when it causes severe detrimental environmental and social impacts similarly most people interviewed by garrido et al in southern spain agreed with the use of hunting to control wild animals when they present a risk to the health of other animals but not when wildlife control was done for other objectives such as to improve game populations when taking into account the different levels of deer impact avoiding unsustainable damage was most valued regardless of the management method this is consistent with results of previous studies that show lethal and more invasive wildlife management options become more acceptable as the threat level by wildlife increases other factors such as the species motivations for the management action and stakeholders involved also explain variations in tolerance to damage recreational hunting in national parks we incorporated in the exercise societal attitudes toward recreational hunting as a tool to address overabundance of ungulates because of the difficulties of financing protected areas and the current debate on hunting in national parks we are however aware of the potential downgrading effect that could arise due to the increase in human activities authorized in protected areas our results showed that a majority of respondents favored control via recreational hunters paying to shoot deer in these parks because this would reduce the cost to the taxpayer of managing overabundance nevertheless some people were not in favor of this option despite the cost implications the best solution is not obvious because no solution satisfies everyone as in many humanwildlife conflicts in a hypothetical scenario where policy changed our results suggest recreational hunting could be a socially acceptable tool to manage overabundance problems in national parks provided some requisites were met however selection of this management tool is not easy for policy makers for example recreational hunting would not be an optimal solution if the manager follows the pareto principle limitations and future research we focused on deer but this species is only an example of a common ungulate that negatively affects ecosystems and human livelihoods over vast agroforestry areas in spain and other european and north american regions societal preferences are context specific and vary in space and time and we highlight the usefulness of environmental economics valuation methods to quantify the perceived welfare changes induced by wildlife control our method may therefore be extended to other ecosystems and species for example elk in north america wild boar in europe and feral horses in australian alps however further considerations may be important when extrapolating methods or results to flagship species such as elephants giraffes and lions because biases associated with charismatics species may come up or when considering irreversible damage and very large territories such as the megaparks in africa and the united states where natural control of wildlife species that reach very high numbers and nonintervention policies can be more successful furthermore future research considering uncertainty in the results of the management programs seems relevant in any case information on how society understands the preservation of ecosystems and how they perceive the relationship between humans and nature is essential because it will inform the integration of society in management decisions which is needed to develop sustainable conservation strategies to mitigate humanwildlife conflicts and to reconcile social concerns with conservation goals in protected areas conservation biology volume 00 no 0 2020 supporting information effects of deer overabundance in the study areas the survey on perception of the overabundance of ungulates in national parks analysis specifications and a comparison of wtp values with the wtp in space and latent class models are available online the authors are solely responsible for the content and functionality of these materials

the extraordinary population growth of certain ungulate species is increasingly a concern in agroforestry areas because overabundance may negatively affect natural environments and human livelihoods however society may have negative perceptions of killing wildlife to reduce their numbers and mitigate damage we used an online survey that included a choice experiment to determine spanish citizens n 190 preferences toward wildlife population control measures related to negative effects of ungulate overabundance negative impacts on vegetation and other wildlife species and disease transmission to livestock in 2 agroforestry national parks in spain we used latentclass and willingnesstopay in space models to analyze survey results two percent of respondents thought a national park should have no human intervention even if lack of management may cause environmental degradation whereas 95 of respondents favored efforts to reduce damage caused by overabundant ungulate species we estimated human wellbeing losses of survey respondents when sustainable effects of deer overabundance on the environment became unsustainable effects and wellbeing gains when sustainable effects transitioned to no visible effects we found that the type of wildlifecontrol program was a very relevant issue for the respondents indirect control in which killing was avoided was the preferred action sixtysix percent of respondents agreed with the option of hunters paying for culling animals to reduce ungulate impacts rather than management cost coming out of taxes whereas 19 of respondents were against this option and willing to pay for other solutions in national parks our results suggest that killing wildlife in national parks could be a socially acceptable tool to manage overabundance problems in certain contexts but it could also generate social conflicts

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introduction indonesia is a nation characterized by religiosity where religion holds a central position and is considered an essential element in national and character building this perspective emphasizes the active role that the state can play in addressing religious issues and providing opportunities for the development of various religions the viewpoint expressed by alfred denning without religion there can be no morality and without fanggi r a manuain o m morality there can be no law underscores a close correlation between religion morality and law this assertion suggests that the existence of law is contingent upon the presence of a supportive society and conversely the development and existence of a society necessitate the establishment of laws to maintain order and the wellbeing of the community therefore the development of the indonesian individual should ideally commence with early childhood education as previously mentioned the emphasis on the psychological development of the indonesian individual should take precedence as it forms the foundational basis for the nations overall development the legal consciousness of society should begin at the smallest unit namely the family environment within an extended family setting members include the father mother grandparents uncles aunts children and other family members however in smaller families only the father mother and children may be present the father as the head of the family leads and guides the family while the mother serves as the homemaker with responsibilities for household management within the family environment it is crucial for the husband and wife as a married couple to maintain harmony if a married couple fails to maintain a good relationship conflicts may arise within the family environment potentially leading to criminal activities which often go unreported due to being considered private family matters this is also influenced by societal tendencies to conceal or hide such matters from the public deeming them as family secrets or disgraceful affairs crimes that may emerge within the family environment include physical violence abuse psychological violence and even sexual violence or molestation against children fundamentally children are unable to protect themselves from various threatswhether mental physical or socialacross different facets of life therefore legal intervention that prioritizes the interests of children is imperative in every child can exercise their rights and fulfill their responsibilities the issue of sexual violence particularly child molestation demands even more intensive and serious attention this is crucial given the tendency for child victims to be frequently overlooked by competent institutions within the criminal justice system which provisions these guarantees are reinforced through the ratification of international conventions on child rights such as the convention on the rights of the child ratified through presidential decree number 36 of 1990 the state government regional governments society families and parents are obliged to provide protection and ensure the fulfillment of childrens human rights according to their duties and responsibilities the protection provided to children thus far has not guaranteed them treatment and opportunities aligned with their needs in various aspects of life therefore the governments efforts to protect childrens rights must be based on the principles of human rights namely respect fulfillment and protection of childrens rights in the implementation of this ratification the government has enacted law according to barda nawawi arief the desire and effort to conduct studies or legal exploration rooted in living laws have been presented in academic forums this desire indicates an awareness of the need to unearth legal norms grounded in cultural moral and religious values on the other hand it reflects a tendency towards dissatisfaction concern and a crisis of confidence in the existing legal system such trends also appear to be prevalent in international congresses in the fields of criminal law and criminology barda nawawi arief mentions that from the statements of the fourth to the eighth united nations congresses there appears to be an affirmation that a development itself is inherently not criminogenic especially when its outcomes are distributed fairly and justly to all citizens supporting the entire social conditions b however development can become criminogenic or increase criminality if the development 1 is not planned rationally 2 has imbalanced or uneven planning 3 disregards cultural and moral values and 4 does not encompass a comprehensive community protection strategy based on the previous explanation the central issue to be addressed in this paper is to examine the current criminal policy regarding sexual violence against children by family members in east nusa tenggara methodology this paper employs a qualitative method as qualitative research deals with issues that are provisional unclear holistic complex and dynamic in the process of law enforcement a comprehensive examination will be conducted on the entire legal subsystem including firstly the legal substance of sexual violence particularly regarding its punitive system with alternatives such as imprisonment and fines secondly the publics understanding of the law itself is also a factor hindering law enforcement because the community may not be aware of and comprehend the applicable positive law this holistic research encompasses all parties responsible for upholding the law beginning with the communitys understanding of the law furthermore in the application of the law itself it is always dynamic meaning that changes may occur based on casespecific observations therefore this research is unlike quantitative research which can determine the research method based on predefined problem formulations and the problem focus has been delimited additionally the resolution of sexual violence cases may involve local wisdom this research is conducted in kupang the approaches employed in this research encompass the statute approach case approach and conceptual approach the data in this article were acquired through participant observation involving a direct review of the handling of sexual violence cases by the kupang city police this included victims of sexual violence perpetrators of sexual violence nongovernmental organizations religious figures and local community elders the focus was on sexual violence cases related to the prevailing law enforcement patterns and the utilization of alternative models as a form or model for resolving sexual violence cases indepth interviews were also conducted with womens and childrens advocates as well as local community leaders to understand the patterns of addressing sexual violence documentary studies involved the examination of case files related to sexual violence a combination of these three methods known as triangulation was employed to ensure the reliability and validity of the findings d results and discussion the use of criminal law must also consider the capacity and working ability of law enforcement agencies ensuring that there is no overburdening of tasks furthermore barda nawawi arief in the symposium report states that to designate an act as a criminal offense it is necessary to consider the following general criteria a whether the act is disliked or condemned by society because it causes harm or has the potential to cause harm inflicts victims or has the potential to inflict victims b whether the cost of criminalizing is proportionate to the results to be achieved meaning the cost of legislation oversight and law enforcement and the burdens borne by victims perpetrators and the criminals themselves must be balanced with the situation of achieving legal order c whether it will further burden law enforcement agencies disproportionately or cannot be realistically undertaken given their capabilities whether these acts impede or obstruct the nations aspirations posing a threat to the entire society the aspirations of the nation therefore pose a danger to the entire society based on the above criteria for criminalization the existence of these legal instruments is already appropriate and fulfills the need for legal boundaries within society however what remains a continuous challenge is the consistency in its law enforcement applying balanced laws to offenders while ensuring legal protection for victims and potential victims statistical data on the resolution of cases of sexual offenses within the family can be seen in the following table if analyzed in table 5 the situation of children as victims of sexual intercourse is generally alarming with the significant number of sexual violence cases against children showing that prevention efforts for this crime are still minimal however in the legal regulations regarding sexual violence discussed in the three legal provisions above the community is also assigned the responsibility to actively participate in prevention efforts and protect children from sexual violence according to em mayers the law is a set of regulations that includes considerations of morality directed toward human behavior in society and serves as a guide for the state authorities in carrying out their duties sudikno mertokusumo also defines law stating that it is a collection of general provisions that regulate behavior the law is general because it applies to everyone and is codified as it regulates something specifying what must be done what must not be done and deciding which part to follow as a guide according to legal dictionaries law is coercive regulations that determine human behavior in the societal environment created by official bodies with the authority to enforce them and violations of these regulations result in consequences being taken every person is entitled to receive legal protection almost every layer of society needs to obtain protection from the law therefore when a child becomes a survivor of sexual violence the state is obligated to provide legitimate guarantees to children through various legislative regulations the necessity of this protection arises because children are a common component of society with physical and mental limitations in this way children require specific safety and care generally the goal of child protection is to provide a sense of security free from both physical and mental threats keeping children the oncall system for ppa duty officers is operational but challenges arise when sexual violence cases are reported after 2200 since ppa duty officers are not on standby 24 hours due to family commitments the spkt duty officer responds to reports after 2200 by contacting the oncall ppa duty officer legal protection for children legal protection for children can be defined as the legal efforts to safeguard various freedoms and fundamental rights of children as well as various interests related to their wellbeing thus the issue of legal protection for children encompasses a broad scope child protection can be categorized into two parts child protection can be carried out directly or indirectly direct protection implies that the activities are specifically directed towards the child who is the direct subject of the intervention these activities may include among others protecting the child from various external and internal threats educating nurturing accompanying the child in various ways preventing hunger ensuring health through various means providing facilities for selfdevelopment and so forth indirect child protection involves activities not directly aimed at the child but at others who are engaged in or involved in efforts to protect the child the position of victims in the juvenile criminal justice system the concept of victims has been extensively discussed by both experts and international conventions addressing crime victims some of these definitions include a arief gosita defines victims as those who suffer physically and mentally as a result of the actions of others seeking to fulfill their interests or the interests of others that conflict with the fundamental rights of the aggrieved party through acts or commissions that violate criminal law in each respective country including abuses of power based on the interview with the head of the child protection division of the department of ppkbp3a in east manggarai regency it was found that the environment where someone resides significantly influences human behavior and the level of crime in the case of violence against children such as abuse molestation and rape most perpetrators are those who are close to the victims and live close to them often victims and perpetrators are individuals residing in remote villages with limited education on sexual violence due to inadequate facilities and infrastructure currently even schools can be places where individuals carry out their reprehensible actions the environment plays a crucial role in human behavior for instance someone who was initially devout and diligent in worship may when joining people in an environment that can be described as deteriorated or prone to intoxication possibly deviate from their religious practices in such environments individuals may witness others freely committing sexual violence against those around them because it is not addressed or punished leading them to potentially follow suit sexual violence crimes not only occur in school environments offices or specific locations that provide opportunities for individuals of different genders to communicate but also within the family the home and family which should be a safe and supportive place for children often become locations for damaging sexual crimes such crimes not only have serious physical and psychological impacts on the victims but also disrupt trust and the social climate family factors are not the sole external factors triggering child abuse social conditions within peer groups schools and unhealthy communities can also lead to child abuse the results of an interview with the head of the women and children protection unit of the east manggarai police usually children from broken home families or children who lack parental affection due to their respective fate will look for pleasure or comfort outside the home so that they have a romantic relationship with someone whose age is too far away for example the case we are handling and are in the process of investigating is known to be an 18yearold child dating a 30yearold adult man who still has a family relationship who lives in the same house and is known to have had repeated intercourse based on the results of interviews and data that researchers found at the research location of the three cases that are being handled by the east manggarai resort police the three perpetrators are the closest people to the victim or people who live in the neighborhood around the victim the perpetrator dp is the uncle of the victim as who lives in the same house as the victim as a result of living in the same house with the victim the perpetrator was free to carry out his actions repeatedly because he met the victim almost every day although in this case the victim and the perpetrator were in a romantic relationship the victim was still a child who should still be under parental supervision it can be said that the living environment is also one of the factors causing crime victim assistance is the process of implementing support for victims to carry out recommended actions and consistently monitoring their progress in terms of victim assistance provided by the ppa technical implementation unit it encompasses health legal aid and recoverypsychological support with the most common needs being psychological and legal assistance psychological services aim to strengthen and help overcome difficulties and problems effectively furthermore medical assistance provided by the ppa technical implementation unit involves providing initial physical health aid to the victim in the case of female victims of violence who are injured the ppa technical implementation unit will refer them to the nearest hospital for preliminary examinations legal services involve assisting and handling victims of domestic violence throughout the legal process from the police level to the court level as well as providing mediation assistance for issues that may not proceed to the legal process conducting outreach and home visits when necessary based on the explanation in the previous section it is clarified that according to soerjono soekanto a role is a dynamic aspect that originates from ones position or status when someone exercises their rights and responsibilities in accordance with their position they perform a role according to merton a role is defined as the expected behavioral pattern that society has for someone occupying a particular status in this context it also relates to relationships based on the sociologically every law enforcer has a social position and a role a social position is a specific place within the societal structure that may be high moderate or low this position serves as a container containing certain rights and obligations and these rights and obligations are referred to as roles therefore someone with a specific position is commonly known as a role occupant where rights are the authority to act or not act while obligations are burdens or duties every role undertaken certainly comes with problems and risks in carrying out its role as an extension of the local government the regional technical implementation unit for the protection of women and children in ntt undoubtedly faces constraints and challenges in handling various issues one of these issues is the handling of domestic violence cases some of the presentations from the ntt technical implementation unit for women and childrens protection regarding these constraints and challenges include human resources and infrastructure shortages based on the interview results with the head of the complaint section he explained in this regional technical implementation unit for women and childrens protection we are still very lacking both in terms of human resources and infrastructure additionally we also do not have a childfriendly space furthermore the head of the followup section explained the majority of cases here are cases of domestic violence in the form of psychological violence therefore we still need more psychologists the lack of human resources and infrastructure in the ntt provinces uptd ppa is also a constraint in handling victims of violent acts the role played by uptd ppa ntt in providing counseling or psychological support to victims of violence is not yet optimal due to the shortage of psychological counselors uptd ppa ntt also faces constraints related to infrastructure such as the absence of a childfriendly space absence during clarification and mediation based on the interview results with the head of the followup section he stated when uptd receives a complaint from the victim and then clarifies it with the victims spouse to ensure the reported case indeed occurred and to hear the perpetrators response to the complaint reported by the victim the lack of active participation by the perpetrator when called is one of the constraints faced by uptd ppa in the ntt province another challenge faced by uptd ppa in the ntt province is the absence of the accused party during the clarification of cases and mediation this hampers the handling process provided by uptd ppa ntt leading to excessive time wastage therefore uptd ppa offers a solution to the victim or complainant regarding whether they want to proceed or not however this is not coercion or encouragement from uptd but rather based on the victims willingness victim not carrying identification card during reporting based on the interview results with the head of the complaint section he stated sometimes when the complainant comes here they often forget to bring their identification card and to enter the system the national identification number is required therefore we accept the report first but we cannot process it until we obtain the nik for reporting into the system insufficient budget one of the main constraints faced by the regional technical implementation unit for women and children protection is the limitation of the budget the limited budget can affect the ability of the regional technical implementation unit for women and children protection to provide the necessary resources such as facilities equipment and training for teachers and staff based on the abovementioned articles it is appropriate to ensure the protection of children from any form of actions that hinder their growth and development one of which is sexual violence against children sexual violence is a phenomenon that frequently occurs within society and often targets children as its victims the incidence of sexual violence against children has been on the rise from year to year including in the city of kupang the following data presents the victims of sexual violence against children over the past three years as obtained from the department of womens empowerment and child protection of the city of kupang kupang police women and child protection unit head bripka bregitha n usfinit explained that most of the perpetrators of child sexual abuse in kupang city are their adult boyfriends with the modus operandi of i love you ill take responsibility later and various other manipulative seductions the perpetrator makes the victim want to have sexual intercourse and it is not uncommon for the victim to be forced to agree to the perpetrators request in addition victims who come to report to the authorities or who come to ask for assistance have usually experienced sexual violence repeatedly and the victims are accompanied by parents relatives or relatives to protect victims of sexual violence in the city of kupang the empowerment of through this cooperation agreement the six parties coordinate with each other facilitating complaints exchanging relevant data and information about the victims providing facilities and infrastructure as well as personnel offering assistance and delivering health and counseling services provide legal assistance the assistance received by child victims of sexual violence includes support from making reports to the police to legal representation during court proceedings wherein the victim is accompanied by a lawyer serving as legal counsel in the city of kupang lbh apik collaborates with the empowerment of women and child protection agency of kupang city and womens house while lbh bifa justicia also partners with womens house to provide legal assistance services both in litigation and nonlitigation contexts consequently cases of sexual violence can be resolved following applicable legal procedures allowing victims to advocate for their rights nevertheless there are still some cases that are resolved within the family leading to the termination of the cases at the police level the head of the women and children protection unit of the kupang city police stated that in some cases we are forced to proceed but the victims have quietly settled them within the family causing these cases to come to a halt midway through this it can be seen that the community of kupang city still lacks awareness of the importance of law enforcement in cases of sexual violence against children by bringing these cases to the relevant authorities for resolution both perpetrators and victims can obtain justice proportionate to their actions perpetrators face criminal sanctions for their deeds while victims are protected and cared for to recover from the pain and trauma inflicted by the perpetrators actions in addition resolving issues within the family is not effective because the problems are simply resolved without the enforcement of justice and both victims and perpetrators are free from potential imprisonment allowing perpetrators to potentially victimize again provide spiritual guidance the provision of spiritual guidance is carried out by religious leaders through collaboration between government and nongovernment institutions and relevant parties one person the budget incurred is quite significant including lab costs of idr 1000000 expert fees of idr 5000000 roundtrip tickets accommodation and transportation rumah perempuan also collaborates with psychologists from rsud wz yohanes they also facilitate health services at local community health centers and hospitals however in the course of their work rumah perempuan faces challenges due to the limited number of psychologists causing difficulties in providing psychological therapy services to the victims provide shelter the department of womens empowerment and child protection of kupang in collaboration with rumah harapan gmit provides a shelter or accommodation for victims of sexual violence the shelter is specifically designed for victims who do not have a safe place to stay and the victims living conditions are not conducive due to the perpetrator being a family member therefore the victim must be separated from the perpetrator and should not meet as not separating them could further harm the victims for child victims of sexual violence the goal of social rehabilitation is to enable them to regain selfacceptance rebuild their confidence and selfesteem and reintegrate into society after experiencing sexual violence application of criminal sanction the imposition of criminal sanctions on perpetrators of child sexual violence is journal of law and sustainable development fanggi r a manuain o m article 81 stipulates a minimum criminal sanction of 5 years and a maximum of 15 years along with a fine of up to rp 5000000000 and an additional onethird of the penalty if committed by parents guardians family members child caregivers educators educational staff child protection officers or by more than one person collectively and recidivists of the same criminal offense the disclosure of the perpetrators identity is also regulated as an additional penalty for sexual violence perpetrators chemical castration and the installation of electronic monitoring devices are prescribed for recidivists and perpetrators whose victims suffer injuries or fatalities specifically perpetrators whose victims experience reproductive loss mental disorders multiple victims severe injuries or fatalities are subject to the death penalty life imprisonment or a minimum of 10 years and a maximum of 20 years following the provisions mentioned in the preceding paragraph imprisonment ranging from 6 to 14 years and a fine of rp 100000000 are the most commonly imposed penalties on perpetrators cases with victims experiencing specific conditions as mentioned above are rarely encountered however article 81 paragraph states that perpetrators may face an additional penalty in the form of the disclosure of the perpetrators identity to make the public aware of the perpetrators identity fostering vigilance and preventing further victims nevertheless this is not included in the criminal sanctions binding the perpetrator even though there are no specific conditions for this conclusion based on the criteria of criminalization the existing regulatory framework is already in line with and fulfills the need for legal boundaries in society however what remains a continuous effort for optimization is consistency in law enforcement implementing balanced laws for perpetrators while ensuring legal protection for victims and potential victims

the issue of sexual violence particularly child molestation demands even more intensive and serious attention this is crucial given the tendency for child victims to be frequently overlooked by competent institutions within the criminal justice systemto address these issues the research collects data through interviews observations and literature reviews the study employs legal case conceptual and comparative approaches result and discussion data and facts still show that the position of children as a group is vulnerable to becoming victims of violent crimes the following is data on children as victims of sexual intercourse that occurred in the period 2018 to 2022 in kupang city east nusa tenggara indonesia based on the data it shows that the number of cases of child sexual violence has fluctuated it increased drastically in 2019 one year before the corona virus pandemic broke out in indonesiabased on the criteria of criminalization the existing regulatory framework is already in line with and fulfills the need for legal boundaries in society however what remains a continuous effort for optimization is consistency in law enforcement

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background switzerland ranks among the top three healthcare systems in the world with regards to healthcare access suggesting a high degree of health equity however switzerland has few preventive strategies against smoking abuse the aim of this study is to clarify whether educational level and citizenship status have an influence on the prevalence of smoking in switzerland and whether there is health inequity related to a lack of preventive strategies methods we based our analysis on publicly available health data published in the swiss governments swiss health survey we compared the prevalence of smoking across the years and correlated these data with levels of educational attainment citizenship status and age results a continuous significant decline in smokers is observed in the highest education group over time prevalence was reduced from in to in p the intermediatelevel educational group showed smaller but also significant decline on a sigificance level over the same period from to p the lowest educational group showed a nonsignificant decline from to the population who holds swiss citizenship showed a decrease in smoking from to within the time frame p people without swiss citizenship had a much higher prevalence of smokers at in and declining to in p all cohorts from age to age have a far higher prevalence of smokers than cohorts at an older age with the highest prevalence in the age group introduction smoking is the greatest avoidable health risk in switzerland it is estimated that around 10000 people die every year from smokingrelated diseases this corresponds to around 27 deaths per day representing almost 15 of all deaths and leading to costs of around 5 billion swiss francs per year fortunately as several reports in recent years have shown there has been a shift in the swiss population with a reduction in the prevalence of smoking for decades there has been a global debate on how to protect people from harms of smoking policy interventions such as limiting access to tobacco and implementing educational programs are frequently proposed as preventive instruments although 50 of 53 countries in the who european region are parties to the who framework convention for tobacco control smoking prevalence varies tremendously between european countries switzerland is one of the few countries that has so far refused to implement the fctc despite the lack of fctc ratification the global tobacco industry interference index was derived in switzerland the score describes the lack of restriction for the tobacco lobby with 92 out of a possible 100 points switzerland is in 79th place in 2021 among the 16 european states surveyed switzerland scored the worst and thus may be considered very tobacco industryfriendly according to the who health equity is the absence of health disadvantages depending on social factors such as age education nationality or socioeconomic status conversely social inequalities in the health system are referred to as health inequity the prevalence of smoking is unfortunately not a universally accepted marker of health equity in addition the determination of prevalence of nicotine use across the whole population does not reveal any difference in prevalence in subpopulations according to previous research individuals who continue to smoke are more likely to have limited formal education and lack access to educational opportunities and they tend to belong to marginalized or underprivileged groups of the population therefore the prevalence of smoking serves as a marker of health equity across different subpopulations switzerland ranks among the top three healthcare systems in the world with regards to access to healthcare and successful treatment of diseases indicating a high degree of equity the high standard of healthcare in switzerland is also reflected in life expectancy with a mean life expectancy of 828 years this is one of the highest in europe and well above the eu average the high standard of healthcare on the one hand and the comparatively high prevalence of smoking on the other result in a contradictory situation while switzerland has made remarkable achievements in social and health care independently of individual socioeconomic background it also has one of the lowest standards in europe for smoking prevention the purpose of this study is to analyze whether the decreasing trend in smoking prevalence observed in recent years in switzerland is supported by the latest data furthermore we aim to clarify whether the relationship between socioeconomic status as indicated by educational level and immigration status and the prevalence of nicotine consumption is a valid one these questions are of particular relevance in switzerland a country with one of the lowest smoking prevention standards in europe methods swiss health survey this study is a descriptive analysis of publicly available anonymous statistical data from the federal statistical office in switzerland and does not require an ethics application our analysis is based on the data published by the swiss governments health survey over the past three decades this survey is part of the federal governments multiyear statistical program and has been conducted every five years since 1992 the represented population includes all persons aged 15 and over who live in private households including people without swiss citizenship the net sample includes 10000 people from the swiss population and changes each time the survey is conducted in addition the individual cantons had the option of increasing the sample size in their canton in order to be able to carry out representative evaluations at cantonal level eighteen cantons and the city of zurich availed themselves of this opportunity in 2017 and financed additional interviews for their areas the net sample of the swiss health survey 2017 thus includes 22134 telephone interviews following the telephone survey a written questionnaire was also sent to the participants which was returned by 18832 people the questionnaire is attached here as an appendix 1 the objective of the survey is to measure the health status of the population determine the development over time and observe the impact of health policy measures in this survey an inhaled tobacco product is interpreted as smoking among the smokers most smoke every day a smaller number are occasional smokers but this group is heterogeneous and not clearly defined to improve clarity daily smokers and occasional smokers are combined into one group of smokers from swiss federal statistical office substitutes such as oral or transcutaneous nicotine administration are listed under a separate heading but were practically nonexistent in switzerland during this period newer forms of inhaled products such as electronic cigarettes are also counted as smoking these products were also scarcely available during this period in switzerland there are no official figures on sales statistics for tobacco products education level for comparison with smoking prevalence the bfs classified the education level attained as obligatory school secondary education and tertiary level obligatory schooling includes two years of kindergarten and nine years of school secondary education includes further education with practical training tertiary levels of education include universities universities of applied sciences and higher vocational examinations the educational profile of the swiss population in 2017 may be broken down as follows 347 with a tertiary qualification 450 with a secondary qualification and 203 with a maximum compulsory school qualification citizenship switzerland has the highest proportion of people with an immigrant status in europe more than 39 of the permanent resident population 15 years and older has a migrant background and about 25 of permanent residents do not have a swiss passport we correlated smoking prevalence between people with and without swiss citizenship to the best of our knowledge this has never been analyzed or published in detail statistical analysis the analysis is based on the original data file of the bfs sud1402esstabac3chxlsx the data were evaluated with the software r by a statistician the plots show the trends in smoking prevalence stratified by educational level citizenship and age respectively for the years 19921997200220072012 and 2017 stratified by education citizenship and age respectively the error bars with the colored shadings reflect the 95 confidence intervals 95 ci pvalues as a quantitative measure to confirm the qualitative observations have been calculated using chisquared test by comparing the frequencies of smokers and nonsmokers between 1992 and 2017 for education and citizenship as well as by comparing the frequencies of smokers with and without swiss citizenship for each year smokers include daily smokers and occasional smokers results smoking behavior in correlation to level of education figure 1 summarizes smoking behavior in switzerland since 1992 values fluctuate but there is a continuous decline evident in smokers in the highest education qualifications group there is statistically significant drop in smoking prevalence from 286 in 1992 to 230 in 2017 the middle education group shows a slight but significant decline over the years with a prevalence between 312 and 291 at the lowest level of educational qualifications the prevalence does not significantly change with values between 279 and 273 the outlying low value of smoking prevalence in the year 2007 with 216 is hard to explain according to statements by the federal statistical office the educational profile of the swiss population is summarized in the material and methods section smoking prevalence in switzerland according to citizenship figure 2 summarizes smoking prevalence in switzerland according to citizenship people without a swiss passport smoke statistically significantly more frequently than people with a swiss passport for both categories there is a strong statistically significant tendency for smokers to decrease over time swiss citizens show a decrease of the overall prevalence of current smokers of 27 nonswiss show a more marked decrease of 66 but the rate of smokers is still massively higher than among people with swiss citizenship smoking rate by age figure 3 shows that there is a relationship between smoking and age and that the proportion of smokers among young people in switzerland is particularly high all cohorts from age 15 to age 64 have a far higher prevalence of smokers than cohorts at an older age with the highest prevalence in the 2534 age group between 25 and 38 of the population in these age groups are smokers the percentage of smokers decreases with increasing age the proportion of 75yearolds and older who smoke has been below 10 since at least 2007 however the low number in this age group may also reflect the fact that smokers in this group meet an earlier death than nonsmokers the very high proportion of smokers in the younger age group is a matter of concern from an epidemiological viewpoint discussion existing research has identified demographic groups who are at greater risk for persistent tobacco use these include individuals who are socioeconomically disadvantaged have lower figure prevalence of smokers in switzerland depending on education level the data show a strongly significant drop in the group with the highest level of education while the drop in the group with sek is less pronounced but significant and for obligatory school the frequency stays at a high level daily smokers and occasional smokers are summarized into one group of smokers the error bars ci with the colored shadings reflect the confidence intervals figure people in switzerland without swiss citizenship show a higher prevalence of smokers than people with a swiss citizenship it should be kept in mind that the group of people without a swiss passport makes up only of the population while hold a swiss passport the error bars ci with the colored shadings reflect the confidence intervals levels of education experience poorer mental health identify as sexual andor gender minorities or belong to racial andor ethnic minorities in the sociomedical context these can be interpreted as expressions of health inequity health inequity is better recognized in countries where disadvantaged social groups are clearly identified and present as a challenge switzerland is considered one of the wealthiest nations globally with a highly regarded healthcare system and one of the highest life expectancies in the world these socioeconomic indicators can be taken as indications of a relatively high level of health equity and equal opportunities the country has a welldeveloped and specialized healthcare system accessible to almost all parts of the population including those from a low socioeconomic background with some exceptions for certain vulnerable groups such as socalled sans papiers which were also not recorded in this study paradoxically switzerland scores among the lowest countries regarding regulations restricting tobacco sales and consumption and hardly any other country in europe is as heavily influenced by the tobacco lobby as switzerland if the inverse relation between health equity and smoking consumption is correct switzerland should see a decrease in smoking in educated people with higher socioeconomic status in our study we showed that people at with highest education level in switzerland had a significant decrease in smoking prevalence over the last years specifically the smoking rate in this group was approximately 29 in 1992 increasing to 32 in 1997 and subsequently displaying a steady decline in each measurement period reaching 23 at the most recent assessment conducted in 2017 conversely the observed reduction in smoking prevalence among individuals with educational qualifications below the tertiary level displayed a less substantial reduction in overall nicotine consumption those with intermediatelevel qualifications exhibited a smoking prevalence rate of around 27 in 2017 while individuals with the level of obligatory schooling qualifications demonstrated a somewhat smaller nonsignificant decline in relative smoking rates with a prevalence rate of 29 in the most recent assessment over the years only minor fluctuations and a slight decrease in the measured values are observed in both groups we cannot explain it why the prevalence is highest among people in the middle education group according to international experience it would be expected to have lower prevalence than the lowest level of education which is not the case in switzerland it could be that this group may be targeted by tobacco advertising but we cannot prove this with data and it would be speculation future federal investigations will look into this question in more detail in addition there is a persistently high rate of smoking particularly among very young people at least starting from the age of 15 this is a clear indication that the protection of children and young people is not sufficient recent data showed that the use of tobacco and nicotine products was more common among swiss adolescents than earlier studies and is more prevalent in switzerland than in most other highincome countries we also found that people without a swiss passport have a significantly higher rate of smoking than people who have a swiss passport the proportion in 2017 showed a smoking rate of 32 among people without swiss citizenship and 26 among people with a swiss passport an unusual discrepancy arises from this data on the one hand switzerland has one of the worlds topthreerated healthcare systems which offers all people including people with low socioeconomic status highquality medical care on the other hand we are facing a significant health inequity where individuals with low or medium levels of educational qualifications are potentially poorly protected from smokingrelated nicotine addiction and with people without a swiss passport and young people are disproportionately affected targeted cessation support for groups with a low socioeconomic background and taxation of tobacco products smokefree environments education campaigns advertising bans and cessation support may reduce smoke related health inequities and prevalence the covid19 pandemic might provide some parallel explanation despite the fact that the swiss healthcare system extensively focused on the health crisis triggered by sarscov2 switzerland saw significantly higher and excess mortality especially among people without a swiss passport and those of lower socioeconomic status compared with the general population such mortality risks associated with social background are welldocumented in many countries especially in minority and disadvantaged populations these effects were observed in countries such as the united states where there is published evidence of higher health inequity especially for socially marginalized groups for switzerland existing datasets are inadequate in demonstrating potential health inequities and more studies are needed to show the existence of social inequity linked to health variables in this highly developed country because the level of educational qualifications can be considered a predictor of the rate of smoking the data should be compared with countries where nicotine consumption through smoking is more strongly restricted countries with strong education systems such as ireland or the united kingdom which have some of the strongest tobacco restrictions in europe could serve as comparators in ireland smoking prevalence has dropped from 41 in 1995 to 13 in 2015 in uk 13 of people smoked in 2021 the comparison with these two countries shows a higher demand in switzerland with a currently estimated smoking rate of about 27 however the comparison also shows that existing measures taken in other countries cannot completely negate smokingrelated nicotine dependence for this reason to further reduce smoking in the population targeting groups according to educational attainment alone would be insufficient just as it is probably not enough to rely solely on stricter rules and restrictions related to cigarette sales or consumption to develop a successful prevention policy there is an interesting example of this namely in sweden between 2004 and 2021 daily smoking in sweden decreased from 16 to 6 among men and women what might have caused this significant reduction one important factor is that smoking rates among swedish males never reached the extreme levels of other european countries giving sweden an advantage in curbing the smoking epidemic a decrease in the number of smokers occurred simultaneously with a decrease in the consumption of snus a traditional oral tobacco product kept under the upper lip hence even before the sales of snus started to increase from an alltime low sales level in 1970 the male smoking rate was at least 20 lower than in most european countries from the 1980s and onwards about 30 of adult smoking men who wanted to quit smoking used snus as a way to help them do so resulting in twothirds becoming chronically addicted to snus importantly women did not use snus to the same extent but still showed the same rate of smoking decrease as men in the period the sale of snus is banned in the eu but sweden was granted an exception and presently 19 of men and 4 of women use it daily whether this can be viewed as a success is controversial and many people are reluctant to name sweden as a model country for smoking prevention since the low cigarette consumption is accompanied by a steady consumption of a nicotine substitute in one norwegian survey in males the use of snus increased the probability of quitting smoking compared with medicinal nicotine products even if this is not the perfect policy it might help reduce health inequity in sweden at least in part however in sweden despite successful nicotine policies people with lower socioeconomic status and lower educational qualification level also showed an increased risk for smoking addiction as in other countries nicotine is among the most potent addictive substances often producing withdrawal symptoms more severe than those associated with cocaine or heroin in addition to the discussion on health equity and smoking prevalence there is another important aspect smoking is also disproportionately associated with people with psychiatric disorders many studies report a positive association between smoking and mental illness with smoking rates increasing with the severity of the disease individuals with mental illness also tend to start smoking at a younger age smoke more heavily and are more addicted to cigarettes than the general population for these reasons discussions should not only address which political and preventive strategies are the strictest or the best above all we should be aware that smokers as individuals are often severely addicted and that a sole focus on education alone does not go far enough these people need help if the aim is for them to stop smoking this study has numerous limitations first the statistical information is based on health surveys that take place every five years in switzerland and in the given data set the information regarding education citizenship and age is split into three separate groups making it impossible to control for these subgroups simultaneously the apparent decrease in the smoking rate in 2007 for the group with obligatory schooling cannot be explained statistically furthermore our study only shows divergent smoking prevalences in different social groups in future studies it has to be discussed whether these groups have differences in morbidity and mortality rates due to smoking a further limitation lies in the analysis of the prevalence among people without swiss citizenship the data employed only provide information on whether or not individuals possess swiss citizenship there is a significant part of the population that has only recently obtained citizenship but is not visible in the data used in our analysis furthermore the imprecisely defined and very small proportion of occasional smokers was combined with smokers as this distinction is rarely differentiated according to the who the last limitation is the sole analysis of the educational qualification level for a more detailed representation of the different populations it would be important to analyze the socioeconomic background of smokers and nonsmokers unfortunately such public data does not exist in switzerland conclusion the findings of this study indicate a correlation that in switzerland a high level of educational qualification is correlated with lower levels of smoking people with lower schooling levels show significantly higher prevalence of smoking swiss citizens have a significantly lower prevalence of smoking than nonswiss citizens since switzerland has the lowest prevention standards and poorly implemented policies against nicotine consumption compared with other countries in europe the high smoking rates can potentially lead to longerterm health consequences and high healthcare costs there is a need to consider how the high smoking prevalence in different groups can be better addressed politically and by adopting the rules of the fcts the sole focus on educational attainment does not seem to be a sufficient reference point for prevention policies this study shows that smokingrelated nicotine addiction is complex and that many different aspects mental health and social determinants come together alongside social and health inequities which will need multifaceted approach to achieve better longterm outcomes data availability statement publicly available datasets were analyzed in this study this data can be found here 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 supplementary material the supplementary material for this article can be found online at 1258272full supplementarymaterial

in switzerland individuals with lower levels of education and nonswiss populations are more susceptible to health risk of smoking this is frontiers in psychiatry frontiersinorg wehrli et al fpsyt despite the existence of a highquality healthcare system that has nevertheless failed to negated health inequities

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introduction older people living with frailty have a highly complex range of needs because of increased vulnerability resulting from ageingassociated decline in reserve and function compromising their ability to cope with every day or acute stressors 1 they are often unable to leave hospital even if they no longer need acute care 2 with negative consequences for their health physical function independence and care needs 3 and the wider service such as staff wellbeing and morale interprofessional relationships and service costs 4 many countries have recognised these challenges and introduced initiatives to reduce unnecessary delays but they continue to rise in england 2 3 4 5 6 and internationally 7 in this study we focus on the national health service in england responsibility for delayed hospital discharges lies with the nhs or local authorities 8 but service fragmentation has meant that collaborative working to ensure timely discharge for oplwf has remained challenging identified problems include care coordination and information sharing between different parts of the system aggravated by shortages in staff with appropriate skills and some hospital staffs lack of knowledge of the needs of oplwf 368 it remains unclear however how these factors interact to impede effective discharge and exacerbate delays we sought to elicit the views of health care professionals working in the nhs on the barriers to effective discharge of oplwf in order to identify and describe some of the less clearly defined problems affecting decisionmaking and organising the discharges for oplwf methods we conducted a qualitative study 9 involving semistructured interviews with hospitalbased doctors and nurses with responsibility for discharging oplwf in one large urban acute care hospital in england we purposefully sampled a higher proportion of senior doctors because of their leadership role in discharging patients and their influence on team and specialty culture and on clinical practice 10 we invited consultants doctors in training and senior nurses from a range of specialities because professional cultures knowledge and practices can vary particularly in relation to the care of oplwf 11 interviews were conducted by two experienced researchers and were based on an interview guide exploring participants experience of caring for oplwf participants were also invited to describe in detail specific anonymised cases of successful and unsuccessful discharges data collection took place over six months in 2017 interviews were recorded transcribed verbatim anonymised and assigned a participant number data were analysed using the constant comparative method based on charmaz constructivist grounded theory approach 12 this involved an inductive and iterative process of close reading of the data coding constant comparison and elaboration of initially constructed themes 13 using the qrs nvivo data management software 14 codes and categories were discussed and reviewed regularly by the author team comprising clinicians and social scientists categories of data and thematic relationships were then identified and written up as descriptive and interpretive accounts as this was an exploratory study we did not plan to arrive at a complete description of all aspects affecting discharge delays but collected data to provide new insights into current understandings results a total of 23 interviews were conducted 17 participants were doctors and 6 were senior nurses eleven worked in the care of older people and 12 worked in a range of specialities including respiratory medicine neurology cardiology surgery renal palliative care emergency department and medical admissions unit some of our findings resonate with existing evidence and reflect wellknown barriers to the discharge of oplwf 1516 for example participants referred to the fragmentation of services requiring skilled coordination that was often not available due to high volumes of work poor communication between staff from different organisations and professional backgrounds and waiting for staff from other organisations to carry out tasks this included completing paperwork the time it takes for families to make decisions sourcing social care packages or placements organising medications to take home and arranging suitable transport while the data relating to these factors were rich and detailed recent research has already provided insights into how they relate to patient safety and delays in hospital discharges 1718 the focus of this paper is participants accounts of less openly acknowledged factors affecting decisionmaking and discharge coordination one of the participants referred to conversations not had to describe how a lack of dialogue with patients families carers and other professionals and failures of communication in the care coordination processes had harmful consequences for patients in relation to their health outcomes and quality of life and the quality and safety of their care other consequences involved admission to hospital when patients may have been managed more appropriately in their own homes or in another care setting inappropriate investigations and treatments and prolonged stays in hospital the reasons for conversations not taking place varied participants accounts indicated that they or others may be feeling inadequately prepared for conversations in an environment that is considered unsuitable for eliciting sensitive information and conducting potentially complex discussions unlike concerns about care coordination across health and social care which are usually openly discussed among colleagues and are part of the public discourse about delayed discharges there were other factors which raised uncomfortable emotions and tensions and were often ignored or avoided participants suggested that important conversations were not initiated about endoflife care treatment limits and whether resuscitation in the event of cardiac or pulmonary arrest should be attempted the topic of death and dying was also often not raised by clinicians and participants reported that patients and families did not ask questions our analysis coalesced around two themes uncertainty compounded by lack of information and the hospital as an unsuitable place for endoflife conversations and care these are developed in the following sections with illustrative interview excerpts from participants a table which summarises the themes constituent categories and further interview excerpts is provided in the online supplement uncertainty compounded by lack of information participants described oplwf as clinically complex and the course of their often multiple conditions unpredictable a challenge identified by several participants was the uncertainty about when someone was approaching the end of life as well as the complexity of clinical decision making and care planning for patients whose conditions fluctuated participants reported how this often led to clinical investigations being ordered and treatments being started when this may not be the best course of action as a profession as a whole the default setting for medics is to do things and it is going to take a bit of time to work out actually not doing things is equally good participant 11 consultant mau some also commented on the ethos of hospitalbased medical practice which was mostly about diagnosis and treatment to preserve life the reluctance to let go of active interventions and instead have important conversations with patients was highlighted the main thing is that you have the conversations about end of life and i think there is a real problem with our health system that the default is to treat and these conversations are not had participant 7 consultant cop the initiation of investigations and interventions was reported to lead to delays because of waits required to carry out tests and get results even if treatment options were limited or absent in case of invasive procedures this could lead to a deterioration in a patients condition the clinical uncertainty was often compounded by a lack of what some participants referred to as collateral information about a patients usual functioning and abilities their social circumstances and a history of events leading to a decision to access hospital care this information is needed to complement the clinical picture and medical history but could only be obtained from someone who knows the patient well such as a relative closely involved in the patients life or a professional carer it was seen to be especially important when a patient was assessed at the emergency department participants consistently reported how the lack of this information undermined safe and patientcentred decision making often leading to inappropriate admission to hospital resulting in further functional decline even if it was collected close to patients arrival at the hospital once they were admitted to a ward this collateral information was at risk of being lost participants account pointed to several reasons for this collecting and documenting this information could not be prioritised over urgent clinical work it was not valued in the same way as information from clinical investigations and considered a relatively low status task compared to clinical work however using and integrating collateral information into medical decision making was considered an important part of the discharge process as this consultant explained that type of information is really useful for us because then we know as clinicians how much we need to investigate acutely whats caused the admission or whether actually a number of factors are already in the history that clearly show why the you need to pool that information combine it with the medical information coordinate that and make sure youve got a safe discharge and you know that would work participant 7 consultant cop despite its crucial role in the care planning and discharge process participants reported that it was often not available leading to delays in discharge the hospital as an unsuitable place for endoflife conversations and care there was consensus among professionals who were not specialists in care of oplwf that the acute hospital was an unsuitable environment to talk to patients and families about endoflife decisions one reason given was the pressure hospital staff were under end of life care is not usually our conversation those conversations are quite difficult im sure weve all been in with somebody whos at the end of life but i dont think weve actually sat down with a patient talking about where they want to be what treatment they want it sounds awful but we havent got the time for that participant 2 senior nurse cardiology the acute care environment such as the emergency department and medical admissions unit were seen a stressful and distressing for patients but if such conversations had not taken place previously they needed to take place now there are clearly patients who should not be resuscitated and its a difficult discussion to have in the cold light of day but it should be had and it doesnt and then actually its a very poor experience for people when it has to be done in here mau participant 19 consultant mau participants highlighted other negative consequences of lack of endoflife decisions the excerpt below relates to the obligation on staff to follow resuscitation protocols in the event of a patients respiratory andor cardiac arrest even when it was clear that the patient was not going to benefit for further treatment if the conversation hasnt happened and the patient has collapsed they are not breathing weve got to start resuscitation procedures participant 4 senior nurse cop in the same way that nurses had to initiate resuscitation procedures doctors in training who provide firstline medical care in the hospital setting followed protocols for diagnosis and treatment this was seen to be particularly challenging in emergency situations such as when a oplwf is in crisis and has been conveyed to the ed in this pressurised environment which requires decisions to be taken quickly difficult conversations about the appropriateness of treatment were not considered an option active treatment was seen to present a less problematic path the junior doctor who sees the ninety year old coming in via the ed struggling to breathe with a nasty chest infection has only so much time so the easiest thing to do is to start them on antibiotics start the oxygen and then they get passed on to mau where the junior doctor there says okay ill do the blood culture ill do this that and then pass the patient on because the conversations take a lot longer and if we think these endoflife and resuscitation conversations should be happening on an outpatient basis with our colleagues for patients with chronic illness or with their general practitioners ideally i think it would be better had they happened previously when the patient was well but had obvious multiple chronic conditions that meant that cardiopulmonary resuscitation was not going to be appropriate participant 6 consultant ed similarly it was suggested that while patients closeness to death often remains uncertain clinical deterioration in those with multiple morbidities tends to follow a predictable path providing opportunities to discuss endoflife decisions before they arrive in hospital in crisis there are an awful lot of people with longterm conditions where theres a relatively predictable trajectory to their illness theyre going to progress to heart failure or renal failure or respiratory failure and its never discussed with people until the crisis and thats not good medicine its not kind medicine participant 23 consultant respiratory medicine however even if such conversations had taken place and decisions had been made the processes for documenting them so that they can be accessed at the right time by other professionals were not deemed reliable participants expressed frustration at information systems designs which did not consistently allow access to such vital information some participants accounts suggested that conversations not had related not only to endoflife and resuscitation decisions but also to plans about future treatments or relief of distressing symptoms in the event of patients sudden deterioration such lack of planning can often lead to patients being admitted to hospital unneccessarily there is an issue with care homes and general practitioners so that the default is to send patients in to hospital so if we know we are not going to operate on somebody and they have got terminal cancer and that we know that their bowel might block off if their bowel blocks off and they are in a care home they will be sent to hospital even though theres nothing we can do about it participant 15 consultant surgery other reasons for inappropriate admissions such as the one just described related to the absence of advanced care planning by primary care and care home staff distressing symptoms experienced by people at the end of life which had not been anticipated resulting in carers contacting the ambulance service and a lack of adequate services to respond to the clinical needs of patients at the end of life in the community out of hours participants accounts described a range of circumstances triggered by a lack of advanced care planning that resulted in futile resuscitation attempts admissions to intensive care units that led to long stays in hospital and poor quality of life in patients final days and weeks and unrealistic expectations by patients and families about the success of cardiopulmonary resuscitation the consequence of these types admissions was characterised by this participant its the worst thing for someone whos old and frail to be whisked into an acute building away from people whove been looking after them people they know to die alone in hospital its not kind participant 23 consultant respiratory medicine many participants expressed similar thoughts about how current practice was lacking humanity and voiced regrets about their inability to better support dying patients discussion the findings of this exploratory study of reasons for delays in the discharge from hospital of oplwf resonate with existing evidence while also identifying less frequently acknowledged factors affecting discharges in particular those relating to the uncertainty about when a frail older person is approaching death such uncertainty can produce anxiety especially for less experienced staff which can lead to feelings of vulnerability and the avoidance of decision making 19 more experienced staff have been shown to be able to tolerate uncertainty and to prefer less riskaverse patient management 20 a strategy to reduce uncertainty is to seek information either in the form of clinical information through investigations and tests or information about patients social background and functional status while the former was described by participants as a frequently used strategy which led to delays in decision making the latter was often frustrated by a lack of time to access or retrieve it the acute hospital environment was perceived as unsuitable for raising topics about endoflife decisions with oplwf because they were likely to elicit uncomfortable emotions for patients and their families several participants suggested that such conversations should be initiated by staff in primary or community care rather than by clinicians in the acute hospital setting whose primary task is to provide short episodes of clinical care diagnostics and curative services in response to urgent threats to health therefore it may be difficult for many clinicians to find the right time or the right way to initiate conversations with patients about decisions they fear they may not be ready for and which they see as intrinsically negative this may be because do not attempt cardiopulmonary resuscitation orders are commonly misinterpreted to mean that all care should be reduced raising concerns that patients may be receiving substandard care there is evidence to suggest that this is indeed the case 21 22 23 an oplwfs arrival at the acute hospital was seen as the start of an almost inevitable process of medical interventions described as unkind medicine by one participant where the environment was seen to be unsuitable for their needs and lacked appropriately prepared staff to provide high quality and safe care for those at the end of life as a result of frailty yet paradoxically hospitals are considered a place of safety when other services have been unable to respond in a crisis fuelling demand on hospital services 2 the current health and social care system is illequipped to receive oplwf who have many complex health and social needs back into community settings so that these patients must remain in acute hospitals increasing their vulnerability the risk of functional decline and greater care needs after discharge as well as the risk of emergency readmission 24 this was an exploratory study in one large urban acute care hospital in england we focused on mostly senior clinicians because they lead clinical teams and decision making on discharge and their behaviour guides that of doctors in training and other professionals while it was important to understand their perspective we were unable to include the views of patients and carers therapists social workers and discharge coordinators we were thus unable to explore the wider context shaping practices around discharge however this study generated insights into problems that are less well acknowledged and have hitherto not been reported in the context of delayed hospital discharges these difficulties were linked to conversations not had about resuscitation and end of life decisions as well as patients personal social and family circumstances our research team comprised clinical and nonclinical members and met regularly to debrief the researchers who carried out interviews the team scrutinised the data and nascent analysis to enable them to be open to developing interpretations and conscious of constructing familiar assumptions 12 the reluctance among patients and doctors to discuss resuscitation and treatment plans for the endoflife are well documented 24 in the absence of conversations about lifesustaining treatment this cycle of silence on issues of death and dying will persist fuelled by multiple barriers such as clinical uncertainties fear of the impact on patients navigating patient readiness and feeling apprehensive about such discussions because of a lack of training or inadequate preparation 25 there are metrics regularly collected on a range of problems in the care process that lead to delays in discharge from hospital for oplwf it is difficult to assess the scale of delays that are due to conversations not had however their consequences are potentially far reaching not only regarding reduced efficiency concerns about patient safety and quality of care and the perpetually increasing numbers of days lost to delayed discharges but also for patients quality of life and their experiences at the end of life there are substantial gaps in the evidence about the skills needed for effective sensitive communication with patients about end of life decisions 2627 frailty and clinical uncertainties compound the problem for clinicians in initiating these conversations however patients understand the need for and are willing to have them 28 clinicians working in the cop who participated in our study reported that these conversations were part of their daily practice however discussing and planning end of life care should not remain the exclusive skill set for those working in relevant specialist areas as the population of oplwf is rising this will become a key priority for all practitioners in health and social care however existing evidence about how professionals can be supported to carry out these conversations in community primary care and hospital settings remains scarce similarly further research is needed to provide oplwf and their families with information and support to feel confident in talking about humane and compassionate care at the end of life avoiding unnecessary investigations and futile treatments this project received ethical approval from the university of bristols faculty of medicine and dentistry research ethics committee all participants provided consent to be interviewed and audio recorded availability of data and material given the relatively small number of participants in one nhs trust their data contains a lot of contextual information which is likely to lead to the identification of individuals therefore to protect the participants anonymity the study data will not be made available competing interests the authors declare that they have no competing interests clinical commissioning group and the

objectives older people living with frailty oplwf are often unable to leave hospital even if they no longer need acute care the aim of this study was to elicit the views of health care professionals in england on the barriers to effective discharge of oplwfwe conducted semistructured interviews with hospitalbased doctors and nurses with responsibility for discharging oplwf from one large urban acute care hospital in england the data were analysed using the constant comparative methodwe conducted interviews with 17 doctors 12 senior doctors or consultants and 5 doctors in training and six senior nurses some of our findings reflect wellknown barriers to hospital discharge including service fragmentation requiring skilled coordination that was often not available due to high volumes of work and poor communication between staff from different organisations participants accounts also referred to less frequently documented factors that affect decision making and the organisation of patient discharges these raised uncomfortable emotions and tensions and were often ignored or avoided one participant referred to conversations not had or failures in communication because difficult topics about resuscitation escalation of treatment and endoflife care for oplwf were not addressedthe consequences of not initiating important conversations about decisions relating to the end of life are potentially far reaching not only regarding reduced efficiency due to delayed discharges but also for patients quality of life and care as the population of older people is rising this becomes a key priority for all practitioners in health and social care evidence for support for practitioners oplwf and their families is needed to ensure these vital conversations take place so that care at the end of life is humane and compassionate

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introduction prospective and retrospective cohort studies conducted over several decades have repeatedly demonstrated associations of childhood socioeconomic disadvantage with adult mortality and cardiovascular disease 12 such early life adversity has recently been more broadly defined to not only comprise economic hardship but also physical and emotional abuse nutritional privation sibling loss parental separation and outofhome care amongst other characteristics 3 children removed from their home into state care also referred to as being looked after or public careare typically placed with a foster family and usually separated from their biological families in order to protect their welfare following parental abuse or neglect or less commonly as a result of their own antisocial behaviour in recent years there has been a secular rise in the number of children placed in care in both the us 4 and the uk 5 with current estimates suggesting up to 4 of the uk population may have experience of preadult care although public care is predicated upon providing a more nurturing and protective environment for children than available via their family of origin there is emerging evidence that in fact exposure to childhood care is linked to poor outcomes as such relative to their unexposed peers children with a history of public care followed into late adolescence and early adulthood are more likely to experience a greater prevalence of teenage pregnancy 6 school exclusion 7 mental health problems particularly depression 89 and substance abuse 710 and be implicated in criminal activity 911 these unfavourable outcomes are apparent alongside substantial socioeconomic disadvantage as characterised by poverty 12 an absence of health insurance in societies without universal coverage 13 low educational attainment and insecure housing tenure 11 notably many of these effects appear to hold after taking into account early life confounding factors including illness and disability suggesting that the impact of care may be independent of other adverse psychosocial characteristics that tend to prevail at the time of care placement while it might be anticipated that this array of shorterterm negative life outcomes will position looked after children on a negative life trajectory into middleage studies exploring the longer term impact of early life care are very sparse most investigators have used a crosssectional design in which participants were asked to recall care as much as six decades after the experience 9111214 so raising concerns regarding recall bias in the only prospective cohort study of which we are aware economic hardship and mental health problems were associated with prior care exposure in a large cohort of swedish children resurveyed at age 55 years 15 but the impact of care on a broader array of outcomes is untested we therefore addressed this gap in knowledge using data from a six decadelong followup of members of a large british birth cohort study in whom care data was prospectively gathered across childhood this study also holds information on harmful health behaviours such as heavy drinking and smoking psychological problems antisocial conduct and uniquely in the context research on the consequences of care cognitive function these data allow us to test the hypothesis that gradients between childhood public care and outcomes apparent in early adulthood will largely extend into middleage methods we used data from the national childhood development study also known as the 1958 birth cohort study 1617 an ongoing closed prospective cohort study 11 surveys have been conducted to date investigators have followed 18558 births occurring in the united kingdom during a single week in the late 1950s in the present analyses we used data from birth to 16 years of age to capture public care and potential covariates while outcomes were assessed at surveys which took place at ages 42 and for cognitive function only 50 years in childhood participant consent was obtained from parents or caregivers and later the study members themselves the study was originally approved by the national health service research ethics committee and latterly the multicentre research ethics committee the present report conforms to strobe guidelines 18 assessment of outofhome care and covariates we ascertained childhood history of public care from prospective surveys conducted when participants were aged 7 11 and 16 years parents were asked has the child been under the care of the local authority now or in the past study members were regarded has having experienced care in childhood if a positive response was provided to enquiries at any of the three surveys we derived three indicators of childhood socioeconomic status as recorded at birth paternal occupational social class as based on the registrar generals social classification of occupations 19 maternal education level denoted by age at leaving fulltime educations and number of persons in the household indicators of childhood health recorded at age 7 included hospital visits for illnesses or medical tests any disability and internalizing and externalizing symptoms as quantified using the bristol social adjustment guides 2021 summary scores were created for the internalizing symptoms of unforthcomingness withdrawal depression and miscellaneous symptoms and for the externalizing symptoms of anxiety for acceptance by adult or peers hostility towards adults restlessness and inconsequential behaviour remaining covariates were maternal age at birth of study member and maternal marital status at birth assessment of adult outcomes all adult characteristics were selfreported at age 42 we assessed occupational social class unemployment receipt of any social benefits by the participant or their partner educational attainment cohabitation marital status and history of homelessness indicators of antisocial behaviour were use of illegal drugs in the past year and having received a criminal conviction we quantified psychological distress using the malaise inventory 22 validated in the general population including the present sample 23 this is a 24item scale in which a score of ≥7 has been used to indicate morbidity in addition to the reporting of symptoms diagnosis was captured using enquiries about being under the care of a medical specialist for depression or being hospitalised in the past year for its treatment alcohol problems were assessed using the cage questionnaire this is also validated screening instrument where a score of ≥2 indicates possible alcohol dependence or abuse 2425 a threshold that has been shown to have predictive capacity for mortality 26 current smoking was based on standard enquiries for alcohol intake study members were asked how many drinks they had consumed in the past 7 days including beer wine spirits sherry alcopops and any other alcoholic drinks heavy drinking was denoted by exceeding specific thresholds for women and men participants were asked how often they take part in any physical activity with low levels being defined by exercising fewer than 3 times a week 27 obesity was denoted by a body mass index of ≥30 kgm 2 as derived from selfreported height and weight 28 study members reported a physician diagnosis of diabetes and high blood pressure other health indices included physical disability denoted by permanent illness or injury for six or more months accidents hospital admissions occurrence of any cancer and general health general health was rated on a standard fourpoint scale accidents were defined as events such as roador sportsrelated injury sexual assault or muggings that required medical attention lastly cognitive function at age 50 was measured with a battery of memory and executive functioning tests which have been widely used in other populationbased surveys 29 memory was assessed by a test which involved memorising words with immediate and delayed recall executive functioning was measured by letter cancellation and animal naming tasks statistical analysis we used odds ratios with accompanying confidence intervals computed using logistic regression to summarise the relationship between childhood care and outcomes at age 42 years while linear regression models produced beta coefficients also with 95 confidence intervals to quantify the relationship between care and indicators of cognitive function at 50 years for all endpoints effect estimates were first adjusted for sex and then for a series of covariates which characterised the early life sociodemographic and health circumstances of the study member as a birth cohort study controlling for age was not required all data analyses were conducted using stata se results in figure 1 we show the flow of study members into the analytical sample in total care history data across childhood were available for 16583 study members of these 11160 participated in the survey at age 42 and 9578 in the resurvey at age 50 years those study members who did not take part in the age 42 sweep were somewhat more likely to have experienced care in preadulthood than participants the same observations were made at age 50 in table 1 we present study member early life characteristics according to history of childhood care contingent upon participation in the survey at age 42 years in this analytical sample 420 had a history of care before age 16 in general children who had a history of being in public care had markedly less favourable characteristics relative to their unexposed peers thus exposed children were more likely to come from socioeconomically disadvantaged backgrounds as evidenced by a greater prevalence of overcrowding manual paternal social class and lower maternal education similarly such children had a higher health burden based on hospital visits disability and internalizing and externalizing symptoms the latter differences being particularly marked given the clear patterning of early life characteristics according to public care exposure we incorporated these factors as confounders in the following multivariable regression models in which we attempted to ascertain the independent relation if any between childhood care and adult outcomes in table 2 we depict the association of experience of public care with sociodemographic antisocial and psychological outcomes at age 42 years following adjustment for sex individuals with a history of childhood care were more than twice as likely to be in a manual social class be unemployed be in receipt of social benefits have only a basic education and have experienced homelessness in adulthood compared to unexposed individuals children from a care background were also markedly more likely to live alone several decades later though there was no apparent link with marital status separate control for potential confounding factors from early life particularly poverty rather than indices of health led to partial attenuation for some but not all associations of childhood care with adult outcomes statistical significance at conventional levels was typically retained however as evident by the absence of unity in the accompanying confidence intervals compared to participants who had not been in public care those with such a history were more likely to engage in delinquency in middleage as evidenced by a doubling of risk of illicit drug use and a criminal conviction while taking into account early social circumstances diminished the magnitude of effects for criminality this was not the case for drug use participants with a history of care were more than twice as likely as those without to have had a diagnosis of adult depression as denoted by being under the care of a specialist andor being hospitalised notably while controlling for socioeconomic position in childhood led to some attenuation of these odds ratio but this was not the case after taking into account childhood distress amongst other health characteristics the carealcohol problems relationship was more marked than for drinking behaviour indeed with the exception of cigarette smoking where a doubling in prevalence was apparent in adults who as children had been looked after the health behaviours of alcohol consumption and physical exertion were not strongly linked to care status individuals with a history of care were almost three times as likely to experience physical disability in adulthood compared to individuals without such a background these individuals were also more likely to report poor general health and cancer from all sites combined there were no clear link between preadult care and later obesity and perhaps as a result relationships with adult diabetes and hypertension were not apparent in figure 2 we show the results from the multivariable models in which we adjust the association between care and adult outcomes for sex sociodemographic and health covariates from childhood most of the socioeconomic outcomes were robust to such statistical treatment other endpoints which were also related to public care based on these more complex models included adult mental health illicit drug use smoking disability and poor selfrated health we also examined if being looked after in early life was related to cognitive function at age 50 years the mean difference in performance on 5 tests according to care status was modest with the exception of letter cancellation speed an indicator of sustained concentration these differences were apparent after sexadjustment but were largely lost after control for multiple potential confounding factors lastly when we repeated all our analyses based on individuals without missing data our conclusions were largely unchanged for both noncognitive and cognitive outcomes discussion the main findings of this study were that a history of public care during childhood was associated with a broad range of negative outcomes in adulthood most consistently socioeconomic factors and antisocial behaviour that is after multivariable adjustment and at conventional levels of statistical significance public care was linked to half of the thirty endpoints featured in the present analyses comprising 67 sociodemographic 22 antisocial 35 psychological 13 health behaviours 28 somatic health and 05 cognitive while these findings may be important given the pernicious nature of several of the outcomes in their own right they may also offer insights into the observation that relative to the general population and net of confounding children who are exposure to care may experience up to three times the rate of premature mortality by middleage 30 31 32 this observation raises the question of how exposure to public care in childhood is embodied in turn elevating mortality in analyses of two cohort studies we have recently shown little evidence of an association between preadult public care and various adult cardiovascular inflammatory neuroendocrine and respiratory risk markers for mortality 3334 while the present results suggest that instead the impact of public care on death may be via social circumstances and potentially some indicators of health our study sample is insufficiently mature to enable us to simultaneously run analyses in which we incorporate data on exposure potential mediators and mortality risk in the only study of which we are aware to have done so indices of socioeconomic position and mental health appear to have some explanatory role in the public caremortality relationship 35 replication and testing using a wider range of potential mediating characteristics such as somatic health health behaviours and criminality as identified herein is now required comparison with existing studies our results of a wideranging association of preadult care with outcomes in middleage broadly accord with evidence from samples drawn from scandinavia 8 us 12 and uk 9 populations followed earlier in the adult life course our findings also seem to corroborate those from crosssectional studies including olderaged groups that relied on distant recall of early life care 9111214 in the present analyses while childhood care was associated with a higher burden of mental health problems there were less consistent relationships with health behaviours and somatic health outcomes thus our findings support analyses of data from the 1970 british birth cohort which found associations between care history and smoking but not alcohol problems or physical exertion 36 we did not find associations between care history and either high blood pressure or obesity although these are not universal observations 1314 to our knowledge ours was the first study to explore the influence of being looked after in childhood on cognition in midlife with both care 33 and cognition 37 being strongly socially patterned we anticipated that care would be related to lower cognitive performance but this was not the case even after basic adjustment the difference in performance on various tests of mental ability according to care status was marginal study strengths and limitations the strengths of our study include the wellcharacterised study participants the prospective measurement of public care across childhood as opposed to distant recall in older age and our use of an extensive range of outcomes which unusually in the context of the present literature allowed us to compare effects within a single population our study is of course not without several limitations first 59 of cohort members with care data took part in the resurvey at age 42 with as shown lower participation rates in individuals with such a history provided there was still sufficient variation in exposure and outcomes in the remaining study members and given that our objective was to explore relationships as opposed to examining the prevalence of a given characteristic attrition should not have impacted upon our findings 3839 second parents may provide a socially desirable response to an enquiry as revealing and sensitive as the public care history of their offspring while we are unaware of any studies assessing the agreement of parental selfreported care with a gold standard such as administrative data in preliminary findings from a metaanalysis of studies of childhood care exposure and adult mortality risk in which we compared the predictive value of care data as ascertained from parental report with electronic records across studies we found that care data collected using each mode were associated with around a doubling of adult mortality rates in those with a history of care relative to those without 40 this suggests similar predictive validity for selfreported and administrative data outcome data were also selfreported on this occasion by the study members as opposed to parents but many of these have been shown to sufficiently valid for the purposes of epidemiological investigation third vulnerable children and families are hard to reach in a research context and it is likely that the present study will not capture data on people who experienced the more challenging of upbringings for that purposeful sampling of such groups would be required alongside unexposed children to facilitate comparison fourth we were unable to examine potentially important care placement characteristics including the impact of duration type reason or stability fifth although we attempted to take into account the early life circumstances of children experiencing care it is not possible to completely separate the impact of the various adversities experienced prior to and during care finally the public care system in the uk has evolved in the several decades since the present study members were children some changes most obviously the establishment of the modern uk protection system in 1973 have seemingly improved the circumstances for this disadvantaged population such that they now receive intervention earlier and experience less placement instability 41 while this raises the possibility that the apparent longerterm negative effects may be diminished for children in contemporaneous care there is in fact evidence that more recent generations of children in foster care still experience subsequent adversity 1342 public health implications and future research directions taken together with the findings of other observational studies there is growing evidence of risk in multiple domains across the adult life course for people exposure to childhood care as with all potential populationbased interventions similarly consistent experimental evidence must now be accumulated in order to inform public policy our results and those of other groups are likely to be informative for the planning and implementation of trials ideally randomised with control groups given the logistical and financial implications of such an endeavour however quasi experimental studies which utilise changes in child protection legislation as an instrumental variable may also have value in the meantime practitioners in health and social care should perhaps more closely monitor care graduates conclusions this study adds to a growing body of evidence of the shorterterm negative impact of public care in childhood on a broad range of outcomes to suggest that many effects extend further into the adult life course than previously understood

objectives to examine if there is an association between childhood public care and adverse life outcomes in middleage methods we used data from the united kingdom 1958 birth cohort study of 18558 babies parents of study members were surveyed at age 7 11 and 16 years when experience of public care of their offspring was ascertained an array of outcomes were selfreported by cohort members at age 42 years and a cognitive test battery was administered at age 50 results 420 38 of 11160 individuals in the analytical sample experienced childhood public care prior to age 16 net of confounding factors public care was linked to half of the twentyeight nonmutually exclusive endpoints captured in middleage with the most consistent effects apparent for psychosocial characteristics 67 sociodemographic 22 antisocial 33 psychological 13 health behaviours 28 somatic health and 05 cognitive conclusions the present study suggests that known associations between childhood care and outcomes in adolescence and early adulthood are also seen in middleage policy implications practitioners in health and social services should perhaps more closely monitor care graduates

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introduction chronic pain is a worldwide health problem and a common experience among children and young people the prevalence of chronic pain in children and young people is high ranging from 14 to 76 gobina et al compared the prevalence of chronic pain internationally among young people and reported that 113 of the targeted population experienced headache 77 backache and 46 abdominal pain pain is defined as an unpleasant sensory and emotional experience associated with or resembling that associated with actual or potential tissue damage and chronic pain is described as pain that persists for three months or more chronic pain can be caused by an earlier injury or ongoing health condition and it may also be an idiopathic illness or a symptom of a nonprogressive disease or it can be the chronic condition of pain itself it often leads to high utilization of health care services by children and young people with pain similarly international studies showed increased visits to emergency rooms outpatient clinics and increased inpatient hospitalizations for young people with chronic pain furthermore children and young people often experience untreated chronic pain and encounter delays in being seen and receiving chronic pain care research indicates that chronic pain also has a widespread negative impact on children and young peoples quality of life it affects physical functioning leading to functional disability interrupting performance of daily physical activities disturbing sleep patterns and diminishing psychological wellbeing leading to high levels of emotional distress anxiety depression and mood disturbances in addition young peoples chronic pain can influence social functioning affecting relationships with family and friends and contributing to social isolation moreover school functionings of children and young people including school attendance academic performance and competence physical functioning and social functioning appeared to be negatively impacted by chronic pain according to the world health organization young people with chronic pain should be treated as having a serious health issue that requires active management using a multidisciplinary approach a uk study found that multidisciplinary treatment followed by pharmacological interventions were effective strategies in managing young peoples pain similarly a swedish study found that 74 of children and young people used analgesics to manage their pain previous studies have also reported the use of nonpharmacological interventions for children and young people with chronic pain in andersson et als study 58 of children and young people used a variety of complementary and alternative medicine to alleviate pain for instance nonvitamin nonmineral dietary supplements thermotherapy and massage hydrotherapy and healthy diet relaxation and cognitive behavioral therapy were also reported to be effective psychosocial treatments for children and young people with pain young people with chronic pain may also benefit from exercising to reduce their pain a further selfpainmanagement strategy that has been used by young people lately are online resources such as youtube webmap and icancope chronic pain applications although a large body of research on pediatric chronic pain exists globally there is a deficit of research on young peoples experiences of chronic pain in saudi arabia thus this paper reports on the experience of chronic pain its impact on participation in everyday life and strategies to manage chronic pain from the perspectives of young people and their parents in saudi arabia materials and methods this paper adhered to the consolidated criteria for reporting qualitative research guidelines reported by tong sainsbury and craig the researchers adopted a social constructivist stance where reality and knowledge are socially shaped by how humans perceive the world and how they interact within it yins approach was selected to conduct the multiple case study because it offered a good structure for how a case study research should be conducted analyzed and reported arguably yins postpositivist stance does not align with the constructivist stance chosen to investigate the research aim which was to explore the reality of chronic pain phenomenon among young people in saudi arabia its impacts on school functioning and its management in school settings however yins approach allowed the researchers to understand how young people experienced chronic pain how and why chronic pain impacted young peoples school functioning how their pain was managed in school settings and why such strategies were used carrying out a multiple case study as proposed by yin allowed the researchers to collect triadic perspectives to better understand the phenomenon of chronic pain this created the opportunity to address the gap in the body of knowledge being researched the multiple case study approach entailed collecting data through semistructured interviews to capture multiple perspectives and to obtain indepth data regarding the chronic pain phenomena from more than one case unit of analysis the boundaries for the cases were determined by the studys settings and contexts the interview guide contained openended questions structured around the study objectives so participants could elaborate on the topics during the interviews in addition the multiple case study facilitated comparison between cases and identification of similar and contradictory findings this study was part of a larger study exploring the chronic pain experience of young people the impact of pain on school functioning and pain management interventions in school settings sampling recruitment and participants purposive and theoretical sampling were used to recruit young people aged between 12 and 18 who met the criteria of experiencing chronic pain for at least three months their parents and their school personnel the initial number of young people who met the above criteria was 25 however 15 young people and their parents refused to take part mainly due to ethical considerations for example some mothers were reluctant to take part because the interviews were being recorded they were reluctant to have their voices on tape because of cultural norms about modesty in the conservative islamic religion purposive sampling was the first strategy for selecting participants since it is the most useful type of sampling in case studies especially when the researcher wants to get a deeper understanding of a phenomenon from informative unique cases or a particular population or when there is a need for an indepth investigation about certain cases an initial sample of seven young people consisting of five females and two males with an equal distribution of the severity of their chronic pain were recruited using purposeful sampling in addition their parents including six mothers and one father and fourteen members of their school personnel were recruited in this purposive sampling phase then theoretical sampling was used as it is the consecutive process which takes place when the initial data collection and analysis have been determined and thus the emergent codes and categories inform the theoretical sampling and data saturation is reached theoretical sampling was chosen to elaborate further on developing codes and categories and test their relationships by recruiting more participants this involved analysing the data and generating a sampling frame specifying the participants characteristics which assisted in informing who to sample next and what probing questions should be asked in the interview therefore further information was obtained from the newly recruited participants until data saturation was achieved theoretical sampling was accomplished by focusing on a heterogeneous sample that included fathers of young people with chronic pain more male young people young people with abdominal andor musculoskeletal pain younger age groups and those who were enrolled in middle schools thus at this sampling stage three additional young peopletwo males and one femalewere sampled and interviewed two of them had abdominal pain while the third had musculoskeletal pain two mothers one father and six members of the school personnel were also interviewed young people with chronic pain and their parents were recruited from one of the largest tertiary care hospitals in western saudi arabia jeddah while school personnel were recruited from the schools of participating young people which were located in either jeddah or makkah cities in saudi arabia the gatekeepers for recruiting young people and their parents were senior nurses and consultants from the female and male adult inpatient wards pediatric inpatient wards and outpatient clinics the school managers of the schools were contacted after written permission was sought from young people and their parents and they were requested to identify assistant principals or counselors and schoolteachers who had cared for the participating young people or who had experienced supporting students with chronic pain the gatekeepers distributed an information letter to eligible participants that included information about the study and the researchers contact details to help young people parents and school personnel understand the research aims and whether to decide to participate participants then made contact with the researcher who explained the study again and reiterated the confidentiality and privacy issues in addition in order to conduct research involving young people the researcher first obtained permission and written consent from the parent this was then supplemented with the young persons assent the study was conducted in the period between may 2020 to november 2020 ethical approval the faculty of health sciences ethics committee at trinity college of dublin dublin ireland and the biomedical ethics committee at the largest tertiary care hospital in the western region of saudi arabia in jeddah reviewed and approved the study additional approval was obtained from ministry of education in jeddah and makkah saudi arabia data collection participants were invited to facetoface telephone or online interviews using microsoft team since the data collection was carried out during the covid19 pandemic assisting to overcome issues like time constraints and restricted public health measures that were raised in response to the pandemic most participants preferred telephone interviews as they were costand timeeffective especially for those living in remote cities and because they were a safer choice during the covid19 pandemic moreover although the use of online interviews for qualitative research has significantly increased using microsoft team was a new software in saudi arabia where most participants felt uncomfortable to consider for data collection the first author fa a female phd candidate and nurse lecturer with expertise caring for pediatric clients conducted all the interviews with young people their parents and school personnel sensitively and facilitated open and safe communication with the participants fifteen facetoface interviews and 25 telephone interviews were conducted and each interview lasted approximately 3585 min all the interviews were conducted individually to avoid any potential influence due to the presence of a third party and to ensure open communication facetoface interviews were conducted in settings of the participants preference namely an examination room in the hospital clinics for young people and their parents and in the student counselors room in school settings for interviews with school personnel all interviews started with an openended question tell me about your pain tell me about your young persons pain or tell me about your experience of working with a young person experiencing chronic pain interviews were audiorecorded transcribed verbatim and translated from arabic to english for analysis since each script may have multiple viable meanings when translated into another language the principal researcher is a native arabic speaker who can understand and communicate a variety of cultural and social expressions furthermore the researcher chose an excerpt from a transcript and invited a colleague who is proficient in both arabic and english to crosscheck the translation the colleague then assured the accuracy of translated scripts participants records including audio records and transcripts were pseudonymized where real names were removed and pseudonyms were given for young people participants for example adam was assigned for one of the young people adams mother for his mother and adams schoolteacher for his schoolteacher data analysis the first author fa reviewed the interview transcripts while the second author ic constantly supervised and reviewed all stages of the data analysis a combination of charmazs constant comparative analysis and yins cross case synthesis analysis was followed to analyze the data as explained earlier yins approach provides a clear framework for how to analyze multiple case studies through cross case synthesis in addition yins approach allows the flexibility to combine different methods of analysis and select the best suited for analyzing case study research thus charmazs constant comparative analysis was found to be the most suitable and thorough method for analyzing the large amount of data obtained by using linebyline coding constant comparative analysis was conducted in three stages open coding where a list of initial codes was generated by carrying out comparison within each interview focused coding where similarities and differences within each case and across cases were identified and categories developed and comparison across cases to generate themes and comprise relevant categories each of the three stages of data analysis discussed above was electronically sorted using the data analysis program nvivo 12 which assisted in grouping related data into thematic sets crosscase synthesis was subsequently used through examining each case study separately and then aggregating the findings in accordance with a common framework of categories or themes that emerged from the individual cases for the purpose of this paper the data related to impacts of chronic pain on school functioning and pain management interventions in school settings were not included therefore this paper reports only on young peoples experiences of chronic pain findings young people who participated in this study included five males and five females and their ages ranged from 12 to 16 years both mothers and fathers were invited to participate and eight mothers and two fathers participated parents had between two and eight children with most having three children sample demographics are provided in tables 12 young peoples experiences of chronic pain were categorized into three themes experiencing chronic pain like a big rock on me… i cannot bear it impact of pain on quality of life pain ruins everything and everyday strategies to manage chronic pain i dont let the pain disrupt my day theme 1 experiencing chronic pain like a big rock on me… i cannot bear it young people and parents explained the experience of chronic pain two categories were developed describing pain describing pain for all young people chronic pain principally emerged from their chronic conditions the age of chronic pain onset ranged from birth to 12 years while most young people experienced pain worsen as they grew older some young people felt pain either at one site such as their back which was the most common site followed by the abdomen and head others felt it at multiple sites pain episodes were noted to occur daily especially before receiving a medical diagnosis for the chronic conditions whereas when the pain was controlled it became intermittent and each pain episode would last for a few seconds to a week young people explained their pain intensity as ranging from mild to severe pain seven young people had faced mild pain while six had experienced severe pain and three were still struggling with severe pain young people used a variety of evocative terms to describe their pain ranging from someone who was hitting squeezing pressing pressuring or breaking them whilst others described their pain as a big rock or a heavy weight indicating that it was a significant burden on them as it were a big rock on me… i cannot bear it i feel something holding me by force… i mean pain holds me everywhere i feel someone is squeezing me almost all young people reported that that their chronic pain was triggered by physical activities andor environmental conditions for instance a young person spoke about how the cold weather would exacerbate her pain when there are lots of cold weather … the pain comes … and it raises so much… it will be strong other triggers for pain included pain and chronic condition management diet injuries insufficient sleep stress or sadness and studying also physiological changes in puberty intensified the pain of two young females with pain when the menstrual period comes to areej the first day she is in a state… she cries and is in pain seeking help from healthcare professionals all young people with pain sought professional help for their pain especially during the onset or the peak of pain health care utilization was used mainly to determine the cause of their pain and to obtain help for their pain almost all young people encountered difficulty understanding the cause of their chronic pain and they had experienced misdiagnosis and delayed diagnosis for their chronic conditions during the onset of pain a mother whose son had received a final diagnosis of crohns disease stated that during the onset of the chronic condition a pediatric physician thought that her sons pain was associated with a psychological issue at first … i took majed to a children doctor… she did for him blood tests and told me there is nothing he is good but his hemoglobin is a little bit low… and she said maybe it is psychological and on allahs willing he will get better experiencing misdiagnosis and delayed diagnosis of chronic conditions appeared to impact significantly on almost all young people leading to repeated diagnostic evaluation procedures delay in medical diagnostic and treatment procedures and consequently delay in managing pain one mother described the challenges of repetitive invasive and noninvasive procedures before finally receiving a conclusive medical diagnosis for her son the whole period 10 days he was hospitalized and every day they were… drawing blood samples… doing blood analysis… and they do not know what the reason is… what problem he has the delay in medical diagnostic and medical treatment procedures were also reported by some young people and their parents for instance one mother described long periods of her child struggling with chronic pain due to the cancellation of the endoscopy appointment and the physicians failure to see the necessity of conducting such a diagnostic procedure another mother reported a constant battle with physicians to obtain surgery for her daughter and that in turn had exacerbated her pain so when i took jumana to the doctor he told me leave her two years after puberty and then come theme 2 impact of pain on quality of life pain ruins everything pain impacted the quality of life for young people in many ways they and their parents described how pain affected the physical psychological and social parts of young peoples lives it was apparent that experiencing pain influenced young peoples lives some young people who had sickle cell anemia reported significant life disruption due to chronic pain you feel lacking in life and you feel that time is flying by … pain ruins everything impact on physical functioning the interference of chronic pain with physical functioning was a common struggle faced by most young people leading them to be immobile and to remain sitting most of the time three of the young people had emphasized the experience of using a physical aid during the peak of pain or being dependent on a wheelchair while we the family were walking in a mall sedras walking was disrupted… so we had to look for a wheelchair to push her … because she was saying i cannot walk … due to joint pain the reduction in young peoples physical functioning presented challenges with daily activities such as helping with home chores performing five daily prayers involving standing raising hands kneeling and sitting was also a challenge especially for the young person whose pain resulted from juvenile rheumatoid arthritis she cannot pray she cannot prostrate and it became difficult for her to kneel the physical impact of pain also affected how young people performed enjoyable activities four young people described how their chronic pain inhibited them from performing well in activities they enjoy such as playing soccer before the onset of pain or pain progression but with the pain during this period i became cold when playing soccer i no longer play as i used to the energy level was another issue described by some young people and their parents pain left young people feeling exhausted fatigued lacking energy and needing to rest hindering them from living normally i did not have power i was not getting up sleep disturbances including sleep deprivation were an issue for most young people five mothers reported that pain prevented their young person from having a good sleep due to repeatedly waking up at night he wakes up from his best sleep complaining eating problems were an additional issue reported by several young people and their parents loss of appetite and stomach upsets were experienced by five young people primarily when their pain flared up he cannot eat anything impact on psychological functioning young peoples psychological functioning was adversely affected by their pain young people and their parents reported several psychological symptoms such as anxiety and changes in mood changes in memory and concentration as well as altered body image and physical appearance anxiety primarily resulted from worries of sudden pain episodes changes in mood related to pain were also reported by young people three mothers reported their young persons loss of interest in engaging in enjoyable activities such as cooking and playing in addition some young people and parents commonly reported feelings of anger and agitation stubbornness nervousness unexplained crying and mood fluctuations i get bothered so easily i get nervy … i used to be patient before some young people also experienced negative thoughts about the pain the pain was seen as a crisis problem very critical unsafe very torturing and spirit ruining five young people experienced difficulty with memorization and concentration they and their parents explained how their memory and concentration had worsened since the onset of pain and how they had struggled to stay focused for example one young person spoke about the effort she had to make to maintain concentration when someone spoke to her no matter what i tried whatever was important about this persons words i could not concentrate young people also spoke about various bodily changes and altered body image resulting from pain and pain treatments two young people experienced changes in physical experience such as hair loss limping gait and functional impairment all these bodily changes affected how young people perceived their bodies for example a young person talked about how ashamed she felt when she perceived peoples stigmatization for her limping gait when i was limping … i hated peoples stares… i didnt want them to stare at me i was feeling embarrassed… that i was young but i cant walk impact on social functioning young people with chronic pain experienced impaired social functioning mainly social isolation all young people and their parents noted social isolation pain was the principal associated factor of being socially withdrawn among most young people for example a young person stated that she would isolate herself when her pain flared up so she would not let her pain affect people close to her when i have severe headache and i am not active with anything that happens in the day … so instead of being cranky and irritable to those who surround me… i isolate myself two young people and their parents noted communication difficulties due to young peoples pain intensity a mother stated her son was not having conversations with her or his siblings during the peak of pain even when i used to talk to him he stared at me like that i tell him hey do you see me so he tells me yes but i do not have the power to speak… even there was no talking between him and his siblings theme 3 everyday strategies to manage chronic pain i dont let the pain disrupt my day despite the difficulties young people were facing due to living with chronic pain they were still attempting to manage the chronic pain through medications and selfcare management strategies taking medications for pain most young people and their parents mentioned the appropriate use of medications to manage pain one young person described how he was continuously ensuring sufficient supply of pain medication at home to relieve his pain at home i keep lots of extra pain relief patches adhering to pain medications was also described by young people and parents one mother stated that she always kept a painkiller in her daughters school backpack as the daughters physician recommended it to avoid pain flaring up i always put a painkiller in her backpack… if she feels pain she takes it because the doctors said once the pain comes to her let her take it till she comes to the hospital so the pain will not increase one young person additionally described her day and night routines of taking medications before going to bed or leaving home to ease pain and go about her daily life i take pills before i sleep to benefit me while i am sleeping… and before i go out of the house selfcare management strategies in addition to pain medications young people and parents found a broad range of strategies to manage young peoples pain young people often used more than one strategy although not all strategies were successful the selfcare management strategies included alternative therapies cognitive strategies bearing pain physical activity spiritual strategies family support and avoidance of pain triggers most young people used alternative therapies such as herbal remedies applying massages to the pain area using hot or cold compressions drinking water and eating healthy food all young people used cognitive strategies to overcome their pain these included positive thinking relaxation and distraction positive thinking about pain was described as accepting the pain being used to pain living life do not let it disrupt you it bothers but it is okay it is not dangerous a source of strength and teaches you a lesson for example one young person explained that although the pain negatively impacted her life she would bear it to continue with her daily life i dont let the pain disrupt my day… i dont let the pain disrupt my studying relaxation was another cognitive strategy that most young people described almost all young people found that lying down and sleeping were helpful to make their pain subside as soon as i lay down or sleep … the second day i come back feeling better distraction was also one of the cognitive strategies though this was less commonly used by young people three young people and their parents noted how they used enjoyable activities to distract their thinking about pain i do not spend time thinking about pain as it would hurt me more for example i draw … so as to occupy myself young people and their parents described how most young people were trying to bear their pain despite how well they could control it one young person who was using painkillers for managing his pain explained when it came to me the pain i did not put on the pain relief patches i said in the name of allah i want to try … i stay trying to control the pain but i could not three young people reported exercising such as walking as a selfcare strategy to manage pain one young person revealed that participation in physical activities eased his pain i walk a little bit so the pain goes away spirituality also played a role in helping four young people to manage their pain most parents explained how their spirituality of being muslims helped them to cope as a parent having a young person struggling with chronic pain for example a mother discussed her belief in allahs plans and his blessings as well as her acceptance to allahs commands and destinies for having a son with chronic pain allah writes what it has good ness … glory be to allah if our allah loves a believer … he afflicted him … so thank allah i accept the decree of allah and his destiny… and i ask allah … to have a mercy on ehabs weakness parents believing in allah seemed to influence positively on their young peoples coping with pain one mother described how she used to encourage her son to remember that having a chronic pain is an allahs command and to be hopeful that allah would ease his pains the young person accordingly mentioned his belief in allahs plan praying and hoping that allah would alleviate his pain i tell him pain is a allahs command thank allah and on allahs will you will get better…and this pain on allahs will will be eased maybe this pain is allahs goodwill you do not know… sometimes i say allah i hope it does not come to me this pain all young people experienced family support which had a significant role in easing the pain experience and overcoming challenges associated with pain for instance one young person stated the help she received from her sister and mother in doing homework and explaining school course materials when missing school sometimes i ask my sister to do homework … i also let my mother explains to me avoidance of pain triggers such as avoidance of physical activities hot or cold weather and adherence to a restricted diet was a common strategy used by young people avoidance of physical activities was the most common strategy noted by young people with chronic pain they reported that they were sitting and resting when needed and reducing movement to avoid pain exacerbation i can go upstairs… i get tired a little bit but then i stop a bit for five minutes and then i continue going upstairs avoidance of environmental changes hot or cold weather was mentioned by the mother of a young person whose pain was caused by sickle cell anemia she stated the avoidance of mountainous places where the weather is usually cold adherence to a restricted diet was a common selfcare strategy among young people with abdominal pain one mother described the diet regime of her daughter since receiving the diagnosis of celiac disease and the significance of acknowledging the food ingredients to avoid pain episodes whatever i buy i must know which companies are certified glutenfree… eight years… and … we have been following the diet discussion these findings illustrate how young people experienced their chronic pain and how pain negatively impacted several aspects of their daily lives however young people were constantly trying to manage their pain to improve their overall wellbeing and normalize their participation in everyday life young people described their chronic conditionrelated pain as having a mild to severe intensity and affecting one or more bodily regions these findings are comparable to those of a recent international survey that gobina et al undertook to find out how prevalent chronic pain is among young people according to the study young people frequently experience both singleand multisite chronic pain young people and their parents also identified individualized pain triggers in the current study which were caused by environmental physical pharmaceutical emotional and physiological factors these factors were also reported in a previous study conducted with young people with chronic pain they reported that a variety of biopsychosocial factors triggered their pain with a high frequency associated with physical trauma medical condition or disability and surgery or other medical procedures seeking help from healthcare professionals was consistent with previous studies findings that young people seek medical advice to determine the cause of pain and find appropriate pain treatments young people and their parents experienced misdiagnosis and delayed diagnosis despite the importance of understanding the cause of chronic pain which has been reported elsewhere the concept of misdiagnosis and delayed diagnosis were associated with multiple diagnostic procedures protracted wait times for medical diagnostic and treatment procedures and a lack of knowledge about options for managing chronic pain these findings accord with a finnish study by sulkanen et al who found that abdominal pain among young people with inflammatory bowel disease predicted a delayed diagnosis for more than six months similarly another study discovered that most young people with systemic juvenile idiopathic arthritis had misdiagnosis in which their pain symptoms were misinterpreted as growing pains or psychological issues or misdiagnosed with other serious chronic conditions the current studys findings suggest that the concept of misdiagnosis and delayed diagnosis were associated with healthcare professionals dismissing the pain experienced by young people this resulted in a delay in diagnosing and treating chronic pain and more suffering and potentially worse health outcomes for young people experiencing pain pain dismissal was seen as resulting from the challenge to diagnose and treat chronic pain as it frequently manifests with few or no objective physiological symptoms and assessment almost entirely depends on client reports these findings highlight how crucial it is for healthcare professionals to better understand define and treat pediatric pain it was also suggested that receiving a medical diagnosis or validation would assist young people living with pain to understand and manage their health conditions the findings revealed that chronic pain impacted on young peoples quality of life especially their participation in daily life including their physical psychological and social functioning similarly other studies have found that chronic pain negatively impacts the healthrelated quality of life of young people in the current study chronic pain affected young peoples sleep quality and energy level leaving them immobile and fatigued experiencing sleep disturbances and limiting their participation in daily and enjoyable activities such as home chores praying and playing similarly several studies reported that lack of sleep and feeling fatigued due to chronic pain were associated with restricting participation in physical activities for young people psychological dysfunction was also reported by young people in this study as affecting their participation in daily life activities most young people reported experiencing anxiety and changes in mood which were also identified in other studies conducted with young people complaining of chronic pain a study by gil et al in usa indicated that young people with sickle cell disease who were found to have a high level of stress and a negative mood were also experiencing an increase in daily pain which resulted in a decrease in participation in daily social and home activities social functioning including social withdrawal was additionally noted in this study to affect young peoples social activities the severity of chronic pain was highly related to young peoples impairment of social functioning which is similar to earlier studies in which young people with chronic pain experienced social isolation and peer bullying and negative friendship quality these studys findings may therefore be used to provide and promote more effective treatments and education to improve the physical psychological and social wellbeing of young people with chronic pain the findings also emphasized the role of employing cognitive behavioral therapy as an effective strategy to manage young peoples pain pain related distress and disability young people and their parents reported how young people used pain management strategies to push themselves to engage in daily activities for as long as possible young people and their parents reported adherence to prescribed pain medications to control pain episodes this finding aligns with the studies of fouladbakhsh et al and harbaugh et al reporting medication use to treat pain among young people a significant finding in this study was the varied selftreatment strategies used by young people one common strategy was the use of alternative therapies mainly herbal remedies which may be due to positive attitudes in saudi arabias culture and people towards complementary and alternative medicine in one study saudi young people aged between 15 and 19 years old reported using complementary and alternative medicine to treat health conditions such as abdominal pain cognitive strategies such as positive thinking about pain were another coping mechanism among young people the notion of positive thinking andor optimism and their roles in reducing pain and pain catastrophizing and improving quality of life were also reported in several studies in this study all young people reported that family support helped them to cope with pain it appears that the families of young people were contributing positively toward coping with chronic pain another coping strategy that some young people and their parents used was the influence of spirituality and religion in managing pain although there is limited research on the role of spiritualty and religions in managing pediatric chronic pain in baetz and bowens study with participants aged 15 years old and older with chronic pain in canada they found that spiritual and religious individuals used positive coping mechanisms more than nonreligious people the results of the current study suggest that living in an islamic culture where individuals believe in allahs power and plan and hope and trust in allah was a significant factor in coping with pain the islamic religion seemed to provide spiritual and emotional support for those young people and provided them with hope optimism and encouragement to fight against the restrictions of their conditions and chronic pain such results are in line with prior research indicating that young people with chronic conditions who trusted in allah strengthened their relationship with him through prayers or religious activities and believed that he was merciful and loving felt less alone were relieved and comforted and had a more optimistic attitude about their health the current studys findings imply that providing young people with chronic pain with the proper support and information from healthcare professionals may help to increase their use of healthy coping mechanisms the findings may also assist healthcare professionals in developing appropriate culturally sensitive pain management strategies that can facilitate normalization strategies and foster resilience among young people with chronic pain further research on the influence of islamic culture on pediatric chronic pain management is recommended limitations there are a number of limitations to this study that should be considered the study included young people who had secondary chronic pain brought on by a variety of chronic conditions which may limit the applicability of the findings to young people experiencing primary chronic pain young people and their parents were recruited from a large tertiary care hospital in the western region of saudi arabia which may explain the limitation of identifying eligible adolescents with primary chronic pain for future research recruiting participants from school communities might assist in identifying students with primary chronic pain as was previously indicated the study was carried out during the upsurge of covid19 pandemic which meant that inperson interviews were discouraged as a result of the strict public health measures participants were offered the option of having facetoface online interviews using microsoft teams or telephone interviews it could be argued that online facetoface interviews would have allowed the researcher to decipher nonverbal clues through observation of body language facial expression and eye contact which may have enhanced comprehension of what was being said however all of the participants who declared difficulty with inperson and online interviews chose telephone interviews this might be influenced by the possibility of not needing to dress modestly in accordance with the conservative islamic saudi culture especially for female participants in addition the workload of having distance learning where participants were required to sit for long hours to meet the need of the school work had affected the participants preference for telephone interviews moreover the flexibility in rescheduling the time and date of telephone interviews was perceived to improve participation rates transportation restriction issued by saudi government in response to the spread of the covid19 pandemic and digital health services that were implemented to help people receive medical care and prescriptions remotely from their homes may have influenced participants perspective and experiences of pain implications this paper presents the first publication that explores young peoples chronic pain experience and participation in everyday life in saudi arabia recognizing the impacts of pain on young peoples lives and its management may raise awareness of the significant demand for a multidisciplinary approach when working with young people living with chronic pain the multidisciplinary approach where biopsychosocial pain development is considered would help young people with chronic pain to participate to their desired extent in their everyday lives in order to assist with the management of chronic pain the multidisciplinary approach should also be aware of sociocultural variables such as the importance of religious beliefs and spirituality in young peoples lives further research regarding chronic pain among young people should include national mixed method studies of individual support required by young people experiencing chronic pain in saudi arabia conclusion since chronic pain is a significant health phenomenon this multiple case study provided an indepth exploration of chronic pain experience among young people who live in saudi arabia the findings indicate that the parents and healthcare professionals working with young people with chronic pain are central to the experience of chronic pain of young people it appears that parents and healthcare professionals responses to young peoples pain could hinder or support young peoples managing their pain and participating in everyday life receiving empathetic support from both parents and healthcare professionals assisted young people to strive for normalcy be resilient and continue with their everyday activities despite experiencing chronic pain data availability statement the original contributions presented in the study are included in the articlesupplementary material further inquiries can be directed to the corresponding authors ethics statement the studies involving human participants were reviewed and approved by the faculty of health sciences ethics committee at trinity college of dublin dublin ireland ethical approval was also obtained from the biomedical ethics at the largest tertiary care hospital in the western region of saudi arabia in jeddah and the ministry of education in jeddah and makkah saudi arabia 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

alsaggaf f and coyne i 2023 participation in everyday life for young people with chronic pain in saudi arabia you feel lacking in life and you feel that time is flying by

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background the severe acute respiratory syndrome coronavirus2 and its resulting disease are spreading rapidly worldwide 1 a better understanding of the predictors of developing infection is essential for health service planning targeting prevention efforts and informing future modelling efforts age male sex and preexisting medical conditions are established predictors of adverse covid19 outcomes as is excess adiposity 2 but the role of social determinants is poorly understood 34 ethnicity and socioeconomic position strongly influence health outcomes for both infectious and noncommunicable diseases previous pandemics have often disproportionately impacted ethnic minorities and socioeconomically disadvantaged populations 56 early evidence suggests that the same may be occurring in the current sarscov2 pandemic but empirical research remains highly limited 7 it is highly plausible that infection risk will vary across these social groups for example socioeconomic disadvantage is linked to living in overcrowded housing similarly bangladeshi indian and chinese households are more likely to live in intergenerational households 8 which has been hypothesised to increase transmission 9 establishing the risk of developing infection across different social groups is challenging a major issue is that information about ethnicity and socioeconomic position are often not well collected within routine health data furthermore the size of the different social groups in the general population is also often not accurately known 10 the ideal approach to estimating infection risk across different social groups is to analyse data from a cohort study but most existing cohort studies which include detailed information about ethnicity and socioeconomic position are subject to long delays in data being available for analysis and are too small to provide useful estimates of infection risk the uk biobank study has carried out data linkage between its study participants and sarscov2 test results held by public health england we therefore aimed to investigate the relationship between ethnicity socioeconomic position and the risk of having confirmed sarscov2 infection in the populationbased uk biobank study methods study design and participants data were obtained from uk biobank with the methods described in detail previously 11 in brief over 502000 communitydwelling individuals largely aged 40 to 70 years were recruited to the study during 2006 to 2010 participants attended one of 22 assessment centres across england scotland and wales data were collected on a range of topics including social and demographic factors health and behavioural risk factors using standardised questionnaires administered by trained interviewers and selfcompletion by computer results of sarscov2 tests for uk biobank participants including confirmed cases were provided by the public health england microbiology database second generation surveillance system and linked to uk biobank baseline data 12 data provided by phe included the specimen date specimen type laboratory origin and result data were available for the period 16 march 2020 to 3 may 2020 since data on test results were only available for england we restricted the study population to people who attended uk biobank baseline assessment centres in england participants who were identified as having died prior to 31 january 2018 from the linked mortality records provided by the nhs information centre and those who requested to withdraw from the study prior to february 2020 were also excluded from the analysis in addition to the analyses of the overall population we also investigated positive test results amongst those who had been tested only this allowed us to investigate the potential for bias due to differential testing between ethnic and socioeconomic groups uk biobank received ethical approval from the nhs national research ethics service north west assessment of ethnicity and socioeconomic position all exposures were derived from the baseline assessment centre data collection ethnicity was selfreported and categorised into white british white irish other white background south asian black chinese mixed or others as more data became available we also used more refined groupings separating south asian into indian pakistani or other south asians and black into carribean african or other black due to small numbers analyses of the chinese mixed and other black groups were limited in line with previous research we also do not report results for the other group due to problems with interpretation of this highly heterogenous group 13 socioeconomic position was assessed using two different measures recorded at the baseline visit arealevel socioeconomic deprivation was assessed by the townsend index corresponding to the output area in which the respondents home postcode was recorded 14 quartiles were derived from the index where the lowest quartile represents the most advantaged and the highest the least advantaged highest education level is a proxy measure for socioeconomic position and usually remains stable throughout the adult life course it was assessed as university or college degree a levels or equivalent o levels general certificate of secondary education vocational certificate of secondary education or equivalent others or none of the above 15 ascertainment of sarscov2 outcomes we defined our primary outcome as having a positive test within the public health england database available through linkage 12 this reflects confirmed infection but does not include symptomatic individuals who have not presented to the health service or not been tested or asymptomatic cases some systemic differences exist in testing threshold for example healthcare workers may be more likely to be tested and therefore observed differences may reflect differences in testing practices to investigate whether differential ascertainment was biasing our results we studied three further outcomes we identified positive cases that had their test taken while attending hospital this group is likely to reflect more severe illness and therefore is less likely to be subject to ascertainment bias in addition we investigated outcomes related to testing practice by assessing the risk of being tested in the overall population and testing positive amongst only those who had been tested higher levels of confirmed sarscov2 infection could arise from higher rates of testing amongst some population subgroups 12 however if this were to occur the likelihood of having a positive test would be lower amongst groups experiencing high rates of testing potential confounders and mediators age group sex and assessment centre were included as potential confounding variables in all statistical models country of birth versus elsewhere was also included given its influence on cultural practices 16 we also included several variables which could reflect potential confounding or mediation baseline health status was assessed using selfreported longstanding illness disability or infirmity selfreported health status and the number of chronic health conditions selfreported from a predefined list of 43 conditions and topcoded at 4 or more based on a previously published approach 17 behavioural factors included smoking body mass index and alcohol consumption other social variables were also considered employment status distinguished those in paid employment or selfemployment retired looking after home andor family unable to work because of sickness or disability unemployment or others for those in work manual versus nonmanual occupation was assessed by asking participants to report whether their job involved heavy manual or physical work participants were asked about the title of their current or most recent job at baseline and these were converted to the standard occupational classification by uk biobank healthcare workers were identified from the soc 2000 codes 22 32 118 611 9221 and 4211 housing tenure was categorised into owneroccupier or renterother urbanrural status was derived from data on the home area population density uk biobank combined each participants home postcode with data generated from the 2001 census from the office of national statistics the number of people within a household was categorised into four groups single person two people three people or four or more people statistical analyses the association between the exposures and the outcomes of interest was explored using poisson regression poisson regression was preferred over logistic regression to allow relative risks to be presented rather than odds ratios which are often misinterpreted 19 robust standard errors were used to ensure accurate estimation of 95 confidence intervals and p values missing data were excluded from the analysis via listwise deletion statistical analysis was conducted using statamp 151 to investigate ethnic differences we initially adjusted for age sex and assessment centre and then in post hoc analyses we also repeated the above with the more defined ethnic groups we followed a similar approach to explore the role of socioeconomic deprivation and education level model 1 was adjusted for age sex and assessment centre model 2 added ethnicity and country of birth model 3 also adjusted for the social variables model 4 adjusted for model 2 plus health status variables model 5 was adjusted for model 2 plus behavioural risk factors and model 6 was adjusted for all previous covariates results a total of 392116 participants were included in the study people with missing data additional file figure s1 for flowchart and table s1 for patterns of missing data by ethnicity and socioeconomic position most of the baseline uk biobank sample in england was white british with the next largest groups being other white white irish and then south asian and black approximately onethird of the sample had a degree and 162 had no formal qualifications in our sample 2658 people had been tested for sarscov2 and 948 had at least one positive test the geometric mean number of tests performed per participant tested was 153 in comparison to the white british majority ethnic group several ethnic minority groups had a higher risk of testing positive for sarscov2 infection and also testing positive while attending hospital black participants had the highest risk with adjustment for the country of birth resulting in little attenuation adjustment for a history of being a healthcare worker and for social factors did additionally attenuate the risk south asians also had an elevated risk of testing positive in model 1 with a broadly similar pattern of attenuation as for the black ethnic group the white irish group also had a marginally elevated risk of having a positive test which attenuated with adjustment for social variables the chinese group had imprecisely estimated risk ratios due to smaller numbers the pattern of findings for hospital cases was similar suggesting that the higher testing rates amongst certain ethnic groups in the community were not skewing the results similarly analyses of the likelihood of testing positive amongst those who had been tested were often higher or the same in these ethnic groups whereas a lower risk would have suggested differentially high testing when using a more detailed ethnicity classification within the south asian and black groups we observed important heterogeneity in the pattern of findings between the indian group and other south asian groups compared to white british risks were largest in the pakistani group followed by other south asians and were more modestly increased in the indian group there were less clear differences in the estimates for black caribbeans and black africans rr 351 and rr 311 in initial models and rr 218 and rr 153 in fully adjusted models respectively in comparison to the most socioeconomically advantaged quartile living in a disadvantaged area was associated with a higher risk of confirmed infection particularly for the most disadvantaged quartile differences in ethnicity and country of birth social factors baseline health and behavioural risk factors all moderately attenuated the association in the most disadvantaged quartile socioeconomic deprivation was also associated with hospital cases while testing was again more likely the risk of being diagnosed positive amongst those tested also tended to be higher rather than lower analyses by education level also showed a higher risk of confirmed sarscov2 infection with the lowest level of education for no qualifications compared to degree level educated while adjustment for ethnicity and country of birth made little difference to the association adjustment for social factors baseline health and behavioural risk factors all attenuated the association somewhat in fully adjusted model we again observed a similar pattern in hospital cases and found little evidence of increased testing amongst the less educated groups discussion several ethnic minority groups had a higher risk of both being diagnosed and testing positive in a hospital setting with laboratoryconfirmed sarscov2 infection in the uk biobank study the black and south asian groups were found to be at greatest risk with pakistani ethnicity at greatest risk within the south asian group similarly measures of socioeconomic disadvantage were also associated with an increased risk of having confirmed infection and being a hospital case for both ethnicity and socioeconomic position we did not find evidence that these patterns were likely to be due to differential ascertainment since although the likelihood of testing was increased the likelihood of a positive test was if anything higher amongst ethnic minorities who had been tested ethnic differences in infection risk did not appear to be fully accounted for by differences in preexisting health behavioural risk factors or country of birth measured at baseline furthermore socioeconomic differences appeared to make a moderate contribution to these ethnic differences our study has several important strengths first by using a wellcharacterised cohort study we can identify a clearly defined population at risk of experiencing sarscov2 infection by combining data linkage with a large sample size this has allowed us to provide empirical data from this pandemic in a timely fashion ethnicity was collected using selfreport which is widely considered to be a gold standard approach 20 and the availability of a large dataset has allowed us to provide empirical data on this crucial policy priority in a timely fashion including a more nuanced appreciation of the risks of infection within different members of the white majority population as well as drilling down into more specific minority ethnic groups 21 our investigation of socioeconomic position has similarly benefited from being able to study different measures and assess the pattern of findings across these the detailed data collected in this cohort has also allowed us to investigate the extent to which observed inequalities are potentially mediated by a wide range of factors including behavioural risk factors preexisting health status and other social variables however several potential limitations should be noted ascertainment bias is potentially problematic and could arise in several ways including differential healthcare seeking differential testing and differential prognosis even so we have been unable to find any evidence to suggest that differential healthcare seeking or testing would explain the observed pattern of findings fig 2 risk ratios for associations between narrow ethnicity groups and sarscov2 model 1 age sex and assessment centre model 2 model 1 country of birth model 3 model 2 healthcare worker model 4 model 3 social variables model 5 model 4 health status variables behavioural risk factors coefficients for the white irish white other mixed chinese black other and other groups are not shown increased ascertainment amongst ethnic minorities would be expected to result in a lower proportion of confirmed cases amongst those tested whereas we observed the opposite one possibility that remains is that some ethnic and socioeconomic groups have a poorer prognosis and are therefore more likely to be admitted to hospital and therefore to be tested 7 however if this were the case the issue of more adverse outcomes amongst these groups remains concerning other limitations include the nonrepresentativeness of the uk biobank study population potentially exacerbated by missing data with those who were more advantaged being more likely to participate and ethnic minorities less well represented there is therefore the potential that the findings in our study may not reflect the broader uk population 2223 however empirical research has found that this may not result in substantial bias in measures of association in the uk biobank study 24 furthermore estimates from other sources of inequalities in covid19 mortality show similar patterns of associations to our results 2526 we have also been unable to fully exclude all deaths that occurred prior to the pandemic due to lack of uptodate linkage to mortality records at present our exposure data were collected some years ago and it is therefore likely that preexisting health risk factors and some social variables have changed although generally most risk factors track throughout life 27 however it is possible that management for chronic health conditions could have been differential across ethnic and socioeconomic groups 28 between baseline data collection and the pandemic period being a healthcare worker was also ascertained at baseline although many who stopped employment in this area have now returned to work 29 lastly due to sparse data we have not explored the role of specific health conditions such as asthma diabetes and high blood pressure which have been shown to be associated with a higher risk of severe outcomes 330 and are more prevalent amongst socioeconomically fig 3 risk ratios for associations between townsend deprivation score quartile and sarscov2 model 1 age sex and assessment centre model 2 model 1 ethnicity country of birth model 3 model 2 social variables model 4 model 3 health status variables behavioural risk factors disadvantaged groups and some ethnic minority groups 3132 however these are likely to operate as mediators rather than confounders administrative data from health services has recently suggested an increased risk of severe covid19 disease within ethnic minority groups the uks intensive care national audit research centre analysed data on 5578 patients admitted to critical care up to 16th april 2020 and found black and asian people comprised a high proportion of total patients although it was unclear whether these higher percentages were biased by most cases being initially seen in areas with high proportions of ethnic minority groups 33 similarly data from the us centers for disease control and prevention also suggest a higher risk amongst black or african american people but information on race was missing for approximately twothirds of those diagnosed 34 analyses of administrative uk data have also suggested increased covid19 mortality in black and south asian ethnic groups 26 which was only partly accounted for by socioeconomic differences 25 however the role of prior health and risk factors was not accounted for academic research on this topic has been limited to date an ecological study of us counties has suggested that more socially vulnerable areas were associated with higher covid19 case fatality rates 35 our study adds substantially to the evidence by finding that ethnicity appears to be an important predictor of laboratoryconfirmed sarscov2 infection that is only partly attenuated by a large range of potential mediators as well as addressing concerns about numeratordenominator bias our results suggest there is an urgent need for further research on how sarscov2 infection affects different ethnic and socioeconomic groups our findings warrant replication in other datasets ideally including representative samples and across different countries as the fig 4 risk ratios for associations between highest educational level and sarscov2 model 1 age sex and assessment centre model 2 model 1 ethnicity country of birth model 3 model 2 social variables model 4 model 3 health status variables behavioural risk factors coefficient for the other groups are not shown pandemic evolves there is a need to monitor infection and disease outcomes by ethnicity and socioeconomic position however data to allow this disaggregation is often not availablerecord linkage could potentially help address this gap particularly in settings where administrative register data are available given the differences in health risks across occupational groups 36 understanding the risks that the full range of key workers experience is also required lastly other social groups such as homeless people prisoners and undocumented migrants experience severe disadvantage and research is necessary to study these highly vulnerable populations too 3738 conclusions the limited evidence available suggests that some ethnic minority groups particularly black and south asian people are particularly vulnerable to the adverse consequences of covid19 socioeconomic disadvantage and poorer preexisting health do not explain all of this elevated risk there is therefore a need to determine why this increased risk occurs an immediate policy response is required to ensure the health system is responsive to the needs of ethnic minority groups this should include ensuring that health and care workforces which often rely on workers from minority ethnic populations have access to the necessary personal protective equipment to ensure they can work safely timely communication of guidelines to reduce the risk of being exposed to the virus is also required in a range of languages 39 previous evidence suggests ethnic minorities in the uk tend to receive reasonably equitable care in many but not all areas 40 however this is not the case in many other countries where the adverse consequences of sarscov2 infection may be even worse sarscov2 therefore has the potential to substantially exacerbate ethnic and socioeconomic inequalities in health 41 unless steps are taken to mitigate these inequalities the data from this study may be helpful to inform allocation of more aggressive therapies in people with severe disease or targeting preventative vaccination to atrisk groups once evidence for such approaches becomes available supplementary information supplementary information accompanies this paper at 1186s12916020016408 additional file 1 figure s1 flowchart of study participants table s1 missing data by ethnicity socioeconomic deprivation and education level table s2 description of the sample by ethnicity table s3 description of sarscov2 test results within uk biobank by ethnicity and socioeconomic position table s4 ethnicity and risk of testing positive table s5 ethnicity and risk of testing positive in hospital table s6 ethnicity and risk of being tested table s7 ethnicity and risk of testing positive table s8 ethnicity and risk of testing positive in hospital table s9 ethnicity and risk of being tested table s10 socioeconomic deprivation and risk of testing positive table s11 socioeconomic deprivation and risk of testing positive in hospital table s12 socioeconomic deprivation and risk of being tested table s13 education level and risk of testing positive table s14 education level and risk of testing positive in hospital table s15 education level and risk of being tested table s16 ethnicity and risk of testing positive amongst those tested table s17 socioeconomic deprivation and risk of testing positive amongst those tested table s18 authors contributions svk kod and jpp conceived the idea for the paper cln conducted the analysis all authors contributed to the interpretation of the findings cln and svk jointly wrote the first draft all authors critically revised the paper for intellectual content and approved the final version of the manuscript the corresponding authors had full access to all the data in the study and had final responsibility for the decision to submit for publication all authors read and approved the final manuscript ethics approval and consent to participate uk biobank received ethical approval from the nhs national research ethics service north west all participants provided written informed consent before enrolment in the study which was conducted in accordance with the declaration of helsinki the study protocol is available online consent for publication not applicable competing interests jpp is a member of the uk biobank steering committee apart from the funding acknowledged below we declare no other competing interests

background understanding of the role of ethnicity and socioeconomic position in the risk of developing sarscov2 infection is limited we investigated this in the uk biobank study methods the uk biobank study recruited 4070yearolds in 20062010 from the general population collecting information about selfdefined ethnicity and socioeconomic variables including arealevel socioeconomic deprivation and educational attainment sarscov2 test results from public health england were linked to baseline uk biobank data poisson regression with robust standard errors was used to assess risk ratios rrs between the exposures and dichotomous variables for being tested having a positive test and testing positive in hospital we also investigated whether ethnicity and socioeconomic position were associated with having a positive test amongst those tested we adjusted for covariates including age sex social variables including healthcare work and household size behavioural risk factors and baseline health results amongst 392116 participants in england 2658 had been tested for sarscov2 and 948 tested positive 726 in hospital between 16 march and 3 may 2020 black and south asian groups were more likely to test positive rr 335 95 ci 248453 and rr 242 95 ci 175336 respectively with pakistani ethnicity at highest risk within the south asian group rr 324 95 ci 173607 these ethnic groups were more likely to be hospital cases compared to the white british adjustment for baseline health and behavioural risk factors led to little change with only modest attenuation when accounting for socioeconomic variables socioeconomic deprivation and having no qualifications were consistently associated with a higher risk of confirmed infection rr 219 for most deprived quartile vs least 95 ci 180266 and rr 200 for no qualifications vs degree 95 ci 166242 conclusions some minority ethnic groups have a higher risk of confirmed sarscov2 infection in the uk biobank study which was not accounted for by differences in socioeconomic conditions baseline selfreported health or behavioural risk factors an urgent response to addressing these elevated risks is required

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introduction in the field of gender roles david lynchs film blue velvet addressed the ambiguity of peoples inner selves and genders through a variety of performances blue velvet mainly contains two males jeffery and frank and two females dorothy and sandy although biologically their sex was divided into two parts male and female different historical situations can make different genders in turn different performances were presented by illustrating their irrational performances lynch demonstrated the erratic gender trouble in a postmodern way in the field of gender performativity judith butler is one of the representatives of gender theorists butlers bestknown performative acts and gender constitution in which challenged conventional notions of gender and developed the theory of how gender performances become the key to gender itself scholars have created different concepts of sex and gender most of the studies were focused on two aspects first illustrating sexual orientation reflected in judith butlers work 1 second exploring dimensions of gender identity disorders 2 however can one person show diverse gender roles has rarely been discussed this research constitutes a relatively new area that has emerged from gender roles gender roles are influenced by the circumstances people stay in which can not be determined by sex simply thus this essay will draw on judith butlers theory of gender performativity to argue the diversity of gender roles in blue velvet in order to analyze judith butlers performative acts and gender constitution this essay includes two relevant sections the first section is about the subversion of the gender roles of jeffery beaumont and frank booth by illustrating the scenes they stay in their acts channel their inner gender roles furthermore by analyzing the gender relations between frank and jeffery this section will describe the uncertainty that gender roles show in two men the second section is focused on the different treatments that dorothy and sandy receive as both women dorothy has two gender roles an active male gender role and a passive female gender role however sandy contains the potential mother gender role and a loving girlfriend gender role that jeffery turns to this section will show why different performances can receive different gender treatments subversion of gender roles of jeffery and frank in butlers theory continuous social performances shape gender reality thus through the continuous outside stimuli that jeffery and frank have received respectively their subversion of gender roles has been shaped differently by making the sense of unreal beauty immediately collapse and the mystery and grotesqueness take their place in the eyes lynch breaks away from the slightly monolithic overly rosy scenery of hollywood films which are no longer just the mainstream of talented scholars and lovely ladies or individualistic heroism by presenting jefferys initiative and passive performance his gender roles are divided into two figures the boyish gender role and the patriarchal male gender role jeffery beaumont as the male protagonist with a decent look who had been seeking clues to a terrible case that was not even relevant to him has two completely different gender roles he seems to be simple firm and righteous however has been seeking some unstable gender roles inside jeffery needs a way to communicate with his subconscious gender in terms gender embodies a special institution as butler claims gender is instituted through the stylization of the body and hence must be understood as the mundane way in which bodily gestures movements and enactments of various kinds constitute the illusion of an abiding gendered self 4 thus jefferys stylization of his bodily interactions with frank dorothy and sandy shows his exploration of himself firstly jefferys boyish gender role includes three figures hotblooded youth obedient child and helpless boy when jeffery explained his plan to have sandy accompany him as they broke into dorothys house sandy thinks it looks like a daydream but its so weird and dangerous as opposed to this jeffery declares that they are going to try it first and nobody will suspect them because they wont think there are two people in the world who are that crazy the most insane people can act the most normal and the most dangerous places are also the safest places it is certainly ignorant and fearless to overturn the dichotomy and treat danger as an ordinary thing as a hotblooded youth when frank visits dorothy dorothy drove jeffery back to the closet to hide from frank when facing unknown dangers jeffery complied with her like an obedient child as figure 1 shows 5 like he unloaded to sandy after all im seeing something that was always hidden im involved in a mystery im in the middle of a mystery and its all secret 5 this unload happens after he peeped through dorothys closet chinks as figure 2 shows 5 jeffery saw frank abusing dorothy during sex jeffery is alluding to an underworld that involves extortion corruption psychopathy sadomasochism and kidnapping he is also referring to frank a brutal crazy and horrifyingly cruel killer nevertheless it wasnt only a narration of jefferys discovery of his situation but also a feeling towards the position of jeffery himself when jeffery was hidden in a closet it seems like he was hidden from a brutal family from something he couldnt even believe himselfhis helpless boy gender after he was done watching and got out of the shelter closet he is confronting his helpless boyish gender role lynch is using double interpretations to form jefferys inside mind and outside scenarios at the same time lynchs scene settings and intentions are not singular just like his protagonists gender roles secondly jefferys patriarchal male gender role depicts violence and arbitrary under dorothys constant requests jefferys reaction ranges from physically refusing to be violent towards dorothy to not hitting her voluntarily at first and finally to not being able to resist absorbing the feeling of sexual abuse in his dreams the transformation is from a male who held fast to the idea of not harming women and not abusing women in any circumstance to a male who abuses women during sex sigmund freud called this defense mechanism reverse formation 6 that is when people do not accept certain impulses and desires they will stand against them to avoid internal conflict and external threats for jeffery the desire for sexual abuse may also be hidden deep inside him which contradicts his moral boundaries by presenting franks bodily interactions with dorothy and jeffery his gender roles are divided into two figures the empathy gender role and the patriarchal male gender role frank booth a most extreme sexual psychopath frank has an empathy gender role when he is performing sympathetic action frank burst into tears while dorothy the singer sang the song blue velvet he treasured her in this scene and he showed mildness and strong empathy also frank however threatened and roughed up jeffery when he discovered that jeffery was also interested in dorothy he used force and patriarchy to control dorothy at the beginning of the film even chopping off her husbands ear these performances of him are very much irrational and unstable by illustrating these irrational acts lynch presents franks erratic gender trouble in a postmodern way franks patriarchal male gender role contains dirty words assault and apathy there is a scene when frank visited dorothy it happened after dorothy found out jeffery hid in her closet and drove jeffery back to the closet to hide from frank dorothy greeted frank hello baby 5 however frank answered in a rude tone shut up its dady you shit head where is my bourbon 5 his figure presents a macho look bossing his wife around the house an unreasonable husband after frank abused dorothy he seemed to regain his usual state and said to dorothy in a cruel tone you are still alive 5 then he opened the door and left leaving dorothy lying on the floor alone according to psychoanalyst maria ponsi people who act on their inner impulses are also indifferent and unconcerned about the consequences of their impulsive behavior for themselves and others when they act they act before they think or they do not think at all for frank his action replaces his thinking behavior and language expression and fully expresses his patriarchal male gender role enactment is also a concept derived from psychoanalysis and refers to the realization or acting out of unconscious fantasies in contrast to the simple act of seeing enactment is more often found in the interaction between two people in a relationship according to classical psychoanalytic theory franks patriarchal enactments are manifested as a series of his intense unconscious emotions feelings and behaviors that are essential a conspiracy of empathy and counterempathy 7 different circumstances behavioral relationships place frank and jeffery in different gender roles firstly jeffery is the genderless child frank is the patriarchal father jefferys acts are milder mostly scattered in tracing peeping and hiding which are more innocent and childish than franks furious rage thus when frank is having sex with dorothy dont you fucking look at me 5 frank commands dorothy after instructing her to open her legs he watches her while lounging on the sofa 5 frank is more like an image of a patriarchal parental figure which is the father this statement makes dorothy the mother in the scene when frank got out of the car and crucifies jeffery frank made jeffrey rub his muscles it is like a stern father giving his son a lecture dorothy tries to dissuade frank in the car where an absurdist singer dances it is just like a scene reminiscent of domestic violence in a childs room secondly jeffery is the malegendered son as well as frank jefferys obedient child and helpless boyish gender role have been described upfront as for frank when jeffery is inhabiting the shadow of a closet frank is trying to get back to a mothers womb after taking a sip of wine frank puts on his mask and inhales while inhaling he goes into another state a state that appears to be a baby figure mumbling mommy 5 and shakily repeating it to which d replies mommy loves you as figure 3 shows 5 baby wants to fuck 5 says frank expressing his primal sexual desire frank puts himself back to his babyhood as a malegendered son on the other hand frank has been shifted on and on to dont you fucking look at me this has been constantly repeated over and over again 5 frank doesnt want his immature desiresthe needs of a childs sexual love for his motherto be discovered he kneels down while gazing at dorothys intimate area and pretends to be inside her womb although he does not want to be discovered frank is unable to take his eyes away because he is too powerful to be restrained the paradoxical emotion frank is attempting to escape is likewise represented by his actions baby wants blue velvet frank asked and dorothy puts a piece of blue velvet into franks mouth 5 frank begins wooing 5 which sounds like a baby indeed the wooing and the panting have mixed together as franks unstable gender roles dorothy and sandy receive different treatments due to the different social scenarios thus different actions they perform make various gender roles dorothy the stereotypical masochist and a poor crazy woman dorothy has two gender roles dorothys passive female gender role has taken a big part in her performances sandy the feminine gendered role of sandy reflects the cohesive character of the american sweetheart sandy is a sweet and kind young woman with a lovely figure who grew up in a happy home as a result of this setting sandy has developed her gender role of a caring loving mother and girlfriend dorothys active male gender role is aggressive and her passive female gender role is helpless firstly dorothys active male gender role is aggressive no way i want to see you get to undress then asking sex from jeffery at knifepoint like a fierce rapist as figure 4 shows 5 making demand has nothing to do with gender however considering an estimated 91 of victims of rape sexual assault are female and 9 male nearly 99 of perpetrators are male 8 the rape dorothy asks for is beyond the females traditional figure of being meek and forgiving secondly dorothys passive female gender role the formality of dorothys passive female gender role has been compelled by society dorothy has been displayed as an object of sexual desire woman as image man as bearer of the look 3 there is a scene when jeffrey lurks into dorothys home to spy on her and caught her undressing from the traditional psychoanalysis this section is a typical male projection the voyeur is male and the voyeur is female jeffreys eyes are also delivered to the viewers eyes and whether the audience is male or female they are forced to obtain the pleasure of voyeurism of women from the male role under a male gaze 3 that is a male voyeuristic pleasure the coining of the term male gaze is a particularly influential and compelling theory the idea is that straight directors fetishize and idealize women in film through fragmentation costuming or any other means possible 9 dorothy as a woman has been in a state of oppression in the movie dorothys physical and verbal expressions are characteristic of female passivity after she has threatened jeffery at knifepoint she then asks jeffery to stand up and after he stands up dorothy kneels down to this position it is an appearance of high status for men and low status for women dorothys masochistic tendency has surfaced at this point dorothy then asks jeffery to come closer what do you want as figure 5 shows 5 jeffery answers i dont know dorothy pulls down jefferys bottom then asks softly dont move dont look at me 5 jeffery just touches her shoulder and she suddenly turns to a vicious face dont touch me or ill kill you 5 after a while she asks in the same soft tone as before do you like that i say that 5 obviously franks fierce behavior has influenced her deeply however she has no hostility towards jeffery at this point she just turns into a mimic figure that yields to franks patriarchal male gender role in order to accomplish certain goals people may mask their emotions and respond to external stimuli with a particular role for instance dorothy pretends to smile to make frank pleased while harboring masochistic inclinations instrumental emotion reactions is another name for these intentional fake emotional responses 10 constructed from prior experiences instrumental emotional responses might be conscious or unconscious just like the unstable gender roles dorothy shows dorothys helpless performance is a characteristic of female passivity after frank abuses dorothy jeffery comes out of the closet and helps dorothy to get up from the floor dorothy is very helpless and asks the question again however grudgingly what do you want jeffery says nothing 5 dorothy claims im scared 5 looking at each other dorothy asks jeffery do you like me 5 jeffery says yes by asking jeffery a serious question and getting the same positive answer dorothy has emerged into the habit that frank has used to treat her she asks jeffery do you like holding me and see my breasts you can feel it 5 she says her nipples are hard and asks jeffery to touch them 5 like a mother who coaxes her child but lewd she is confused however trying to please him anyway dorothy closes her eyes and asks do you like the way i feel 5 jeffery says yes dorothy then asks feel me hit me 5 she puts forward a masochistic request jeffery firmly refuses she cries and asks him to hit her having been treated rudely by frank she somehow has formed a habit of masochistic need like butler claimed gender is an act broadly construed which constructs the social fiction of its psychological interiority and gender is only socially compelled and in no sense ontologically necessitated having been socially compelled by franks abuse dorothy has transformed from a healthy familys wife to a crazy masochistic dorothy has pinned her hope on a male she has just met a few days before just because jeffery is submissive to her this causes her feminine passivity to be magnified in reverse the second time jeffery comes to her dorothy asks you think im crazy dont you i want you to stay dont hate me 5 it is an action from a female who lacks love jeffery said he doesnt hate her at all dorothy says im not crazy i know the difference between right and wrong 5 she is not crazy before enduring from frank she is once a common wife and mother indeed and she does remember being normal she says to jeffery you are my special friend 5 it helps me i need you 5 this sense of need for him will help dorothy to get through her life the help that she needs is to have trust in her mind so that she can endure the mental torture frank sends in this scene dorothy and jeffery are like a couple who has just gotten together as jeffery says i will call you 5 dorothy asks soon 5 at this point their intimate manners are caught by frank frank shouts directly to dorothy hey who is this fuck 5 she quickly explains that jeffery is her friend who lives in the neighborhood and they are just chatting she has made up an excuse to let jeffery stays out of trouble dorothy tries to interject that jeffery is a nice guy and frank scolds her to shut up when frank is showing his fatherly figure dorothy is the female without a voice at the end of the movie dorothy reunited with her son and they played happily on the lawn just like a normal mother did david lynch presents that once peoples gender roles become peaceful the social environment also exhibits a peaceful and mild image this also highlights the turmoil of dorothys gender roles in a turbulent and dark situation sandy contains the potential mother gender role that tolerances jeffery and a loving girlfriend gender role that understands jeffery sandy s femalegendered role fits the american sweetie unified figure which gives jeffery a sense of security by being a nice and warmhearted girl she is the only one who truly understands jeffery she needs to be protected by men as a potential girlfriend the reason why jeffery talks to sandy each time he finds something isnt just for sandy the daughter of a policeman but sandys nice loving female gender role as a girlfriend in her outfit compared to dorothys dark and sexy style sandy always wears pink and light colors from her wellspoken conversations she is full of hope and making a positive impact on jeffery however sandy is also a potential mother that jeffery turns to she provides him love trust and tolerance after jeffery talks with the detective he seems ready to let go of the whole case sandy emerges from the darkness in a pink dress and points out to jeffery where dorothys apartment is located she seems to have given jeffery the motivation to move forward and explore again with this tone of her patient encouraging performances sandy is shaped into a loving mother gender role when a person is a baby we consider a mother to be a good mother if she responds to the childs needs for example by nursing when the baby is hungry when she fails to respond to our needs we think of her as a bad mother 11 sandys good mother image responds to jefferys needs repeatedly and promptly so that this good experience is repeated over and over again and gradually jefferys mind comes to possess a good mother image that is the good inner object this good relationship gives jeffery a sufficiency of living 12 when no one can give jeffery companionship comfort or affirmation sandy does the presence of a good inner object and a good relationship give jeffery the positive response he needs for example when jeffery asks her desperately like a hopeless child why are there people like frank why is there so much trouble in this world 5 sandy makes her speech about her dream of the robin as figure 6 shows there is no robin so their world has turned gloomy the darkness lingers for a very long period and the robins stood for love thousands of robins are suddenly freed with them they have brought the blinding light of love as if only love could fix anything there will be problems up until the robins arrive 5 jeffery responds to sandy by grinning the sound of the approaching dawn serves as the soundtrack conclusion in summary this paper argued that even one person can have multiple gender roles according to the existing scenes of blue velvet each characters performance shows at least two gender roles in different contexts jeffery and franks subversion of gender roles is related to their individual life experiences dorothy and sandy are treated differently because of their varied social performances these four protagonists result in similar or different gender roles uniquely peoples gender roles are susceptible to their behavior choices it follows that gender is not a fact it is an act that relies on the circumstances people encounter it has multiple exhibitions and it exists when it is performed under certain scenarios the gendered body performs its function in a limited corporeal space enacting interpretations within the limits of preexisting directions by going deeper the exploration of the four protagonists psychoanalysis strengthens the case for identifying various gender roles in each person this argument helps me to conclude that people identify with each other due to the idea of what their behavior means to be in certain scenarios which change from scene to scene david lynch presents that once peoples gender roles become peaceful the social environment also exhibits a peaceful and mild image this also highlights the turmoil of characters gender roles in a turbulent and dark situation this essay intended to contribute to the subject of gender roles by applying how gender reality is refashioned in judith butlers essay even in works that are traditionally seen as rebellious gender roles are explored in david lynchs movie blue velvet as a symptom of the intricacies and persistence of dominant cultural myths

this essay aims to illustrate how gender performativity exhibits gender roles in david lynchs movie blue velvet this essay brings about the collapse of the stereotyped traditional binary opposition of gender roles gender roles rely on the performance of people however peoples performances are restricted by society which has various possibilities based on performative acts and gender constitution 1988 by judith butler this paper analyzes four protagonists various gender performances in blue velvet by going deeper into the psychoanalysis of protagonists and analyzing their behavior choices this essay argues that lynch intends to inform his viewers that there is no fixed gender role even in one single person through exhibiting the diversity of gender roles various social environments are presented david lynch believes that once peoples gender roles become peaceful the social environment can also exhibit a peaceful and mild image this finding contributes to the subversion of gender roles in blue velvet

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introduction as the covid19 pandemic continues to claim more lives health systems globally have been severely strained the consequence has been mounting pressure on frontline health care workers 1 being at the heart of delivering essential health services during the pandemic frontline workers face an increased burden and risk of developing physical and psychosocial problems 2 studies of previous infectious disease crises such as sars h1n1 and ebola reported that frontline workers suffered from poor emotional and social functioning depressive symptoms and insomnia all in addition to the distress relating to the risk of being infected and infecting their loved ones 3 4 5 likewise emerging literature on covid19 consistently indicates a myriad of physical psychological and social challenges faced by frontline workers including burnout posttraumatic stress symptoms anxiety and depression 67 learning from the experience of prior public health emergencies it has been suggested that support for the mental wellbeing of frontline workers is a requisite strategy to ensure a healthy and resilient workforce capable of providing a sustained covid19 response many institutions worldwide have begun to develop wellness intervention plans to support frontline workers during the pandemic 8 9 10 these programs have included specialized mental care clinics employee assistance counseling and hospitalbased interactive activities 1112 however with few exceptions the majority of the psychosocial support and wellness programs have been based on inperson interventions or oneoff support without much consideration given to sustained monitoring and impact assessment organizations such as nhs digital in the united kingdom and the us department of health and human services have underlined the importance of using mobile technology to improve access to care 1314 there is also a growing recognition that information and communication technologies have the potential to address the many challenges faced by the public and frontline workers during public health emergencies 15 this technology focus has led to a surge in the development of mobile health apps during the ongoing covid19 pandemic 1617 according to recent review studies a total of 29 mhealth apps pertaining to covid19 have been developed by 19 countries 18 yet all of them were exclusively designed for contact tracing and symptom management with the primary purpose of containing disease transmission despite increased rhetoric and enthusiasm for wellness support for frontline workers via virtual platforms there remain limited advances toward developing psychosocial interventions using mhealth technology for this population more importantly little research so far has been undertaken on how frontline workers perceive mhealthbased support to meet their psychological needs and challenges during the ongoing covid19 situation in light of the dearth of literature this study aimed to explore frontline workers experience of conventional psychosocial wellness programs and their perceptions of the usefulness of mhealth apps and various features for promoting wellbeing the study also sought to identify factors that could potentially influence uptake and retention of mhealthbased wellness support programs exploring frontline workers perspectives as end users will inform future efforts to design evidencebased and usercentered mhealth interventions in this study we adopted nudge theory as a way to better understand perceptions of mhealth app features designed to support psychosocial wellbeing nudge theory is a novel concept that affects the process of decision making in individuals through choice architecture 19 the theory has been widely used to develop mhealth apps in general and has also been applied to interventions promoting mental wellbeing a growing body of literature has demonstrated evidence of nudge elements that promote health behavior and optimize user outcomes with varying degrees of effectiveness in mhealth interventions 20 for example a study by wiecek et al highlighted that use of reminders is a successful intervention component for mhealth apps to improve medication adherence as participants are regularly nudged to take their medication 21 martin et al called for the incorporation of gamification in an mhealth app as it motivates the user to adopt intended behavior through gamified activities 22 social influence has also been considered an important nudge that increases the effects of intervention outcomes by fostering a feeling of belonging to a community with a common goal 23 individualized tailoring has been found to be an effective nudge in sustaining user engagement for digital mental health interventions 24 25 26 in addition provision of appbased resources yielded a positive outcome that alleviated chronic stress of working women 27 taken together nudge theory has proved to be useful in effecting behavior change for mhealth interventions ahead of the design of an intervention to support the wellbeing of frontline workers we sought to explore their views and preferences for app features that underpin these key nudge strategies methods setting and participants this qualitative study was conducted in singapore during the peak of the covid19 outbreak from april to august 2020 singapore is a multiethnic citystate in southeast asia although the countrys public health care system consists of a team of highly trained health care professionals and efficient services the surge in covid19 infections placed considerable strains on the health system 28 mass outbreaks in foreign worker dormitories in april 2020 spurred the governments decision to impose a 2month lockdown 29 the evolving outbreak situation posed unprecedented risks that could compromise the wellbeing of frontline workers in response a multidisciplinary task force of the singapore general hospital the largest public hospital in singapore swiftly rolled out a wellness program aimed at mitigating the risk of burnout and adverse stress reactions among frontline workers the program included operational and psychological education provision of a written handout for family members active support of staff who were involved in highrisk areas and close communication between peer support leaders and clinical team members it is against this background that a study was conducted to explore perceptions of frontline workers about mhealth apps to improve their wellbeing the study was introduced to clinical teams at the singapore general hospital and community care facilitieslargescale institutional isolation unitsat their staff meetings participants were identified using official websites the study teams professional networks and recommendations from other study participants in this study we defined frontline workers as those who were doctors and nurses and in direct contact with suspected and confirmed covid19 patients and provided essential health care services potential participants were invited to participate by email and were provided with background information we used a purposive sampling approach to maximize the diversity of experiences and opinions as the data collection and concurrent analyses progressed the variation in emergent themes was explored by recruiting subsequent participants for focus groups and interviews based on profession and years of experience to improve our understanding of specific aspects of the studied phenomenon prior to interviews informed consent was sought via email data collection a semistructured interview guide was developed based on relevant literature and the study teams expert knowledge 30 31 32 major topics included perceptions of the existing wellness program available for frontline workers perceived usefulness of mhealth apps for mental wellbeing features that might be valuable for improving wellness and factors affecting adoption of mhealth apps for wellness in addition selfreported demographic information such as age gender ethnicity and years of experience in health care were collected during the interview various visual materials collated from existing mhealth app features for wellness promotion were presented to facilitate the discussion these materials were organized according to key nudge strategies commonly used for mhealth app development 3334 they included but were not limited to the following strategies framing tailoring reminders social influence guidance social modeling gamification and resources 19 these strategies enabled a structured way to collect participants perspectives on the usefulness of mhealth features for improving wellbeing due to the constraints of participants working hours consented individuals took part in either a oneonone interview or focus group discussion subject to availability for safety reasons all interviews were conducted virtually over zoom by two interviewers trained in qualitative research reflections and memos were written after each interview to capture insights interviews lasted 31 to 65 minutes this study was approved by the national university of singapore institutional review board data analysis all interviews were audiorecorded following consent and were transcribed verbatim thematic data analysis was undertaken using grounded theory a grounded theory approach based on the work of glaser and strauss was chosen because it explored experiential aspects of psychosocial programs and how participants perceived the usefulness of key features in a wellness app the grounded theory approach allowed for emerging constructs and themes through iterations of data collection and analysis 3536 two independent coders reviewed the interview materials summarized and extracted meaningful statements and carried out open coding and axial coding using nvivo 12 a qualitative data analysis software during open coding transcripts were analyzed to develop categories of information this allowed for subthemes to be derived from the data instead of preexisting ideas during axial coding common subthemes were grouped into unifying themes the iterative process of independent coding and consensus meetings continued until no new emergent themes were identified the codes were independently applied to all transcripts and coding discrepancies were resolved by iterative discussions lastly for mhealth features themes were mapped against the nudge strategies to assess participants preferences for particular features and their reasoning 34 for rigor and transparency we anchored our methodology according to the consolidated criteria for reporting qualitative research checklist 37 results characteristics of participants a total of 42 frontline workers participated in 12 oneonone interviews or focus group discussions two oneonone interviews and 10 focus group discussions were conducted comprising 21 doctors and 21 nurses the recruitment rate was 93 a total of 3 individuals out of 45 declined participation for reasons of lack of time and disinterest during the peak of the covid19 outbreak health care workers from a variety of clinical departments had been deployed to frontline clinical duties participants clinical home departments ranged across anesthesiology dentistry community nursing and cardiology among others data saturation was reached after the 10th interview with no new themes emerging from subsequent interviews we conducted two additional focus groups beyond data saturation to ensure that the point of information redundancy had been achieved table 1 shows the characteristics of participants including 21 doctors and 21 nurses out of 42 76 of participants were female and 64 were chinese the mean age of the sample was 296 years with slightly more than half of the participants aged 30 years and below participants experience in the health care sector ranged from 2 to 18 years experience and perceptions of the conventional psychosocial program table 2 shows the experience of participants regarding the existing wellness program and their coping strategies by and large the wellness program was perceived to be appropriate with some participants expressing positive thoughts about the educational nature of the session in particular junior doctors who had never experienced an outbreak response appreciated the opportunity to learn how to protect themselves and where to find resources in the event of burnout however as the program comprised a oneoff session delivered to a mixture of different health care teams some expressed the need for building rapport and relationship to enhance the experience as one participant noted the session was felt to be a random group meeting with strangers a minority of participants were not aware of the programs existence the inherent absence of team spirit and social connectivity coupled with limited awareness seemed to discourage frontline workers from active involvement most participants preferred that the program session be organized according to clinical teams a recurring theme was that informal helpseeking appeared to be the most common avenue to ameliorate the emotional fallout from work for our participants the majority indicated seeking support from family and friends when there was emotional exhaustion this was more apparent for participants who had limited awareness of the formal support program or felt that the current program did not meet their expectations importantly participants commonly noted that they often could not recognize their own symptoms of burnout the cumulative psychological effects of burnout at times unwittingly resulted in high anger expression and feelings of frustration when prompted some participants cited constant fatigue and physical exhaustion amid longer work hours as the main reason that limited their ability to selfidentify psychoemotional signs and symptoms illustrative quotes theme and subthemes experience of formal wellness program i think the program was okay but the group was huge so i think sometimes people might be a bit shy to share feelings in a large group the social workers gave us their contact details after the session which was good as we can call whenever we need help but i feel some people might not utilize them as there was no prior rapport built greater need for building rapport and relationships i was not aware of that wellness program but i do know that there are such services for the covid perceived usefulness of features in wellness mhealth apps table 3 presents perceived usefulness of various features for an mhealth app across seven nudge strategies 14 themes emerged it was commonly perceived that using reminders to nudge individuals to monitor their own psychological wellbeing would be helpful in improving selfawareness particularly when tracking was visualized in a graphic form for easy interpretation as one participant noted the tracking feature would allow for reflection on stressors by alerting users of the presence of mood deterioration however frequent notifications were seen as an annoyance in addition to the tracking feature participants valued a personalized goalsetting feature which could aid them by altering them to diet and sleep patterns almost all the participants desired a builtin chat with a counselor as it would offer greater convenience and enable ready access to professional care compared to the conventional mode of inperson counseling however many participants did not appreciate the artificial intelligencedriven chatbot due to the loss of human interactivity they expressed hesitance toward this feature although some recognized that it might be useful for simple tasks such as requests for mental health resources to enhance the user experience the acceptability of a framing feature was explored given frequent changes in work protocols in light of the covid19 situation and its consequential work demands occasional messages and coaching were favored compared to daily push notifications which were seen as an annoyance participants felt that the former would offer a sense of human touch without causing intrusion into private life under the social influence nudge strategy features such as forum chats and inapp peer support groups were seen as an essential component of psychosocial support despite the positive perceptions of the social influence features participants highlighted that proper safeguarding measures should be in place to ensure appropriate balance between freedom of expression and emotional manipulation especially by users who post malicious comments related to this some participants had concerns about disclosure of their personal wellbeing state that might inadvertently affect assessment of their work performance this concern was more salient among junior doctors the gamification function a widely used nudge strategy to improve selfefficacy was not something participants were keen to use while a minority saw a gaming strategy as entertainment most believed that competition via scoring may be demotivating and backfire when individuals fall behind their peers and colleagues virtual rewards such as earning badges intended for triggering competitive natures were generally received in a negative light appbased resources such as mindfulnessbased exercises and short wellness articles were highly valued as a handy and useful tool in promoting a healthier lifestyle and mental wellbeing illustrative quotes theme nudge strategy and categories reminders i think the feature can help me to record when is the day that i am feeling low or happy regular inapp tracking of a mood trend perceived as a tool for improving selfawareness of emotions mood monitoring you can keep track of your progress and monitor your mood eventually you can see a trend which might potentially help you to identify stressors in daily life i wont mind using it regular inapp tracking of a mood trend perceived as a tool for improving selfawareness of emotions progress tracking i do not like this idea periodical receipt of push notifications as i find it to be annoying but as long as there is this option of turning it off then it is fine frequent notifications being felt as a distraction push notification for engagement tailoring i think this feature feedback is a good thing i wouldnt mind using it as it allows me to understand better where i have done great and in which area i can work to improve my mental wellbeing feedback system aids users in making beneficial changes tailored feedback i think being able to set goals like exercise for half an hour a day or sleep before 11 pm might promote healthy living setting personalized goals are perceived to be improving general wellbeing personalized goal setting guidance if you are having some emotional issues you probably wouldnt want to talk to a robot who might not even understand your question properly loss of human contact for emotional support is deemed meaningless artificial intelligencebased chatbot i think the chat with a counselor might be helpful as it is pretty hard to get an appointment with them and with the builtin feature one can get a response almost immediately inapp counseling providing greater convenience and access to care compared to conventional mode of interaction chat with counselor i think we do a lot of texting nowadays so i think texting with a counselor might help especially if the counselor does not know our identity so privacy is guaranteed while getting your problems sorted out with a professional enabling anonymous care chat with counselor framing a message like this personalized message might encourage me to check on myself more frequently it feels like someone is concerned and telling me to take care of myself personalized messages offer a sense of human touch personalized messages social influence although it may be useful for sharing experiences and support one another we will definitely need moderators to watch out for potential bullying or manipulation on the forum in a support group you can still have other people playing the role as a whistleblower but for an anonymized forum chat there may be someone who will keep posting malicious comments emphasis on anonymity for concerns about risk of emotional manipulation and privacy forum for people who require emotional support but choose not to share their problems in a facetoface format i think this is a handy feature to have inapp tutorials and short readings perceived as handy and useful mindfulnessbased exercises some people may want to look for useful articles and if the articles are provided in the app itself it will be really convenient and can potentially benefit a lot of people it would be good if they are presented in point form inapp tutorials and short readings perceived as handy and useful selfhelp aids factors that could affect adoption and sustained use of a wellness mhealth app factors that could potentially influence the adoption of a wellness mhealth app among frontline health care workers are presented in table 4 three overarching factors and nine themes were identified technical factors with the themes perceived ease of use convenience security and information technology support personal factors with the themes perceived usefulness perceived vulnerability and awareness and external factors with the themes rewards and price of app participants noted that nonintrusiveness with a minimum set of features relevant to the needs of frontline workers would be of prime importance in prompting adoption and ensuring continued use as one participant noted a simple interface that requires minimum manual input was one of the most desired features for continued use a robust it and security system was also brought up by participants to help them start or continue using an mhealth app a few participants did not consider an mhealth app as necessary for promoting their mental health and wellness mainly because they felt that they were coping well nonetheless they thought that such an app might be helpful for colleagues who require psychoemotional support or who are keen to improve their wellbeing increasing awareness of the availability of an app would be vital to its adoption to encourage and sustain usage affordable pricing of the app and attractive rewards could be considered to motivate users cost was one of the determining factors for app adoption the majority of participants favored a free app or were willing to pay a small amount if it lived up to their expectations more tangible and extrinsic rewards such as continuing professional education points and taxi credits after accruing virtual points for adherence were also suggested as motivation to sustain usage figure 1 summarizes the factors that may influence adoption and sustainability of a wellness mhealth app for frontline workers table 4 factors affecting potential adoption and sustained use of wellness mobile health apps illustrative quotes factors and themes technical factors i will use the app if it is easy to use i think judicious use of color might catch peoples attention perceived ease of use because we are always using the phone if you are feeling down at least you can use the app to help you manage your emotions i think it is quite convenient and handy convenience a moderator has to be present to watch out for potential bullying and malicious comments in forum chats so as to make people feel safe security and privacy it will be good if there is a team of dedicated it personnel to ensure the app is running well and to minimize the potential hacking and leaking of information information technology support personal factors i guess for the general health care workers it the app might be useful in helping them to manage their emotions better as there are many features that i feel are quite useful such as the virtual counseling service and peer support tangible benefits i might not use the app routinely as i have been coping well but for some colleagues i can tell they are struggling with burnout if the app is introduced to them i feel they are likely to use it perceived vulnerability to wellness risks many people did not participate in the wellness program simply because they were not aware or did not feel the need to same thing for the app it has to be made known to us before we can decide to use it awareness of app external factors i think you need some rewards to encourage usage apart from cpe continuing professional education points i think it will be great if rewards like grocery vouchers and taxi credits can be exchanged with the points we have accumulated in the app rewards and incentives i stopped using previous mhealth app because they wanted to charge a lot so if your app is free then it will be wonderful i will totally use it cost discussion principal findings this study sought to build on limited literature by exploring the perceived usefulness of mhealth apps and features to improve psychosocial wellbeing from the perspectives of frontline workers responding to the covid19 pandemic previous studies have suggested that psychological interventions could help frontline workers cope with emotional exhaustion and could ameliorate workinduced stress during public health emergencies 83839 and that counseling reduces the risk of depression in frontline workers 40 however our study found that our current inperson counseling has limitations in its ability to monitor and manage physical and mental health issues faced by frontline workers our participants who are working on the front line commonly reported that lack of rapport and limited continuity and awareness of the program inhibited uptake and appreciation of inperson counseling and psychoemotional education this finding from our study reinforces that from a previous study that insufficient rapportbuilding led to diminished utilization of wellness support services among frontline workers 31 these factors together underscore the importance of developing an optimal set of psychosocial interventions that address pertinent concerns and needs of frontline workers delivery of psychological interventions through digital devices can possibly help in overcoming some of the barriers identified with the potential for wide implementation in a convenient efficient and costeffective manner 41 current evidence indicates that mhealthbased interventions increased accessibility to counseling and psychoeducation and improved resilience among health care workers 4243 leveraging digital platforms to provide wellness support to frontline workers may be a viable approach consistent with previous research frontline workers generally had limited ability to recognize their psychological problems 44 constant exposure to a highintensity work environment and chronic fatigue appeared to impair the participants ability to recognize their psychoemotional signs and symptoms hence assisting frontline workers to identify their symptoms early in the process could be an important strategy for mitigating the risk of developing severe mental health issues to this end it is encouraging to note that frontline workers in our study desired a reminder functionality such as tracking of mood and psychological stress to understand their own mental health states another mhealth app feature that was highly valued by the frontline workers was inapp resources this finding is consistent with evidence from previous studies indicating that reminders in mhealth apps played a vital role in improving emotional wellbeing for instance regular monitoring of mood was found to be associated with timely detection and mitigation of potential stressors 45 routine inapp reporting of thoughts and feelings can increase emotional selfawareness which in turn fosters coping skills 46 a recent randomized controlled trial demonstrated that mood tracking resulted in improved coping ability better adaptive response and enhanced selfcare 47 likewise inapp resources such as meditation and mindfulness exercises were found to have a positive effect on improving subjective wellbeing and behavioral regulation 48 therefore future mhealth interventions should incorporate key nudge strategies that are favored by frontline workers into the design to increase effectiveness it has been wellrecognized that social support such as being esteemed valued and part of a social network of mutual assistance is strongly associated with improved mental health 49 50 51 perceived availability of social support may bolster ones ability to cope with challenges providing an avenue for emotional expression our study found that informal helpseeking from family and friends or nonhelpseeking were prevailing practices for frontline workers in response to emotional exhaustion associated with covid19 frontline workers commonly reported the need for ongoing social support and desired an mhealth app with features that would enable them to readily access and check in with a virtual peer support community indeed having similar experiences during the pandemic peer health care workers may be in a unique position to provide practical and emotional support a systematic review showed that digital peer support interventions led to improved selfcoping and adaptation 27 through candid sharing of experiences and validation of feelings appbased peer support embedded in a social influence nudge strategy could complement existing inperson support and have a positive impact on frontline workers psychological wellbeing 52 there was however a common concern among our participants regarding potential risks arising from virtual peer interactions such as the spread of misleading information derogatory comments and disclosure of personal mental health issues therefore an appropriate safeguarding mechanism should be in place to ensure the best possible outcomes for frontline workers despite several mhealth features that were valued by frontline workers a crucial issue remains to be considered adoption and sustained engagement a recent study reported that nearly 70 of users abandoned mhealth apps after a single use or stopped using the apps after a month 53 this trend could stem from various factors participants in our study reported that mhealth app technicality and intrinsic factors were critical for uptake and retention this finding resonates with prior research 54 and highlights that a simple user interface would be one of the most important aspects of an mhealth wellness program for frontline workers communicating the benefits and relevance of the wellness app as well as transparency of data management would be equally important for the successful implementation of an mhealth app 5556 in contrast to prior literature frontline workers were more inclined to engage with a wellness app if external incentives such as cpe points were offered 57 therefore it may be helpful to consider incorporating app features that can be manipulated to optimize incentive effectiveness to maintain engagement of frontline workers strengths and limitations this study added important evidence to the potential for wellness interventions delivered through an mhealth app from the perspectives of frontline health care workers findings from this study could provide valuable insight into the development and implementation of mhealth apps for improving the wellbeing of frontline workers involved in the response to covid19 notwithstanding its strengths this study was limited in several aspects the results of this study were derived from qualitative research alone which is by nature prone to a degree of potential subjectivity despite our efforts to recruit a balanced mix of genders almost threequarters of the participants were female this might have introduced potential selection bias into the study however we did not find any considerable gender differences in viewpoints on key topics of interest the discussion on mhealth features during the interviews was primarily based on visual materials underpinned by nudge strategies thus participants responses might have been influenced by the mhealth features presented lastly the study participants were limited to doctors and nurses further research is needed to explore perceptions of mhealth app features to support wellbeing among administrative and ancillary staff as well as allied health care professionals working on the front line conclusions emerging technologies hold considerable promise for significantly expanding the reach of wellness programs for frontline health care workers traditional facetoface modes of episodic support in times of public health emergencies seem to have limited utility to monitor and address the needs of frontline workers in a timely and holistic manner our study highlighted the need to take into account frontline workers preferences and values when designing mhealthbased models of care to promote their wellbeing future work should focus on developing a nonintrusive and personalized app with inapp counseling and peer support features to improve wellbeing as well as tangible and extrinsic rewards to foster continued use conflicts of interest none declared multimedia appendix 1

background frontline health care workers are experiencing a myriad of physical and psychosocial challenges amid the covid19 pandemic there is growing recognition that digital technologies have the potential to improve the wellbeing of frontline workers however there has been limited development of wellness interventions using mobile health mhealth technology more importantly little research has been conducted on how frontline workers perceive mhealthbased support to promote their wellbeing objective this study aimed to explore frontline workers experience of conventional psychological wellness programs and their perceptions of the usefulness of mhealth apps and features for promoting wellbeing it also sought to identify factors that could potentially influence uptake and retention of an mhealthbased wellness programwe conducted semistructured interviews using purposive sampling with frontline workers involved in the covid19 response various visual materials collated from existing mhealth app features were presented to facilitate discussion interviews were audiorecorded and transcribed verbatim thematic analysis based on grounded theory was undertaken themes were subsequently mapped to key nudge strategiesthose commonly used for mhealth developmentto assess participants preferences for particular features and their reasoning results a total of 42 frontline workers participated in 12 oneonone interviews or focus group discussions frontline workers generally had a limited ability to identify their own psychological problems and liked the reminders functionality of the app to track their mood over time a personalized goalsetting feature ie tailoring and inapp resources were generally valued while frequent coaching and messages ie framing were seen as a distraction the majority of participants desired a builtin chat function with a counselor ie guidance for reasons of accessibility and protection of privacy very few participants appreciated a gamification function frontline workers commonly reported the need for ongoing social support and desired access to an inapp peer support community ie social influence there were however concerns regarding potential risks from virtual peer interactions intrinsic motivational factors mhealth app technicality and tangible rewards were identified as critical for uptake and retention conclusions our study highlights the potential of mhealth apps with relevant features to be used as wellness tools by frontline health care workers future work should focus on developing a nonintrusive and personalized mhealth app with inapp counseling peer support to improve wellbeing and tangible and extrinsic rewards to foster continued use

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introduction accepting income diversity by households is regarded as a crucial step in breaking the vicious poverty cycle other conditions being equal income diversity adoption should offer greater revenue to the household the household will spend the extra income on both consumable and nonconsumable goods reducing the prevalence of poverty and enhancing the welfare of the household income diversity may or may not have a significant impact on household welfare but it is generally acknowledged that it is becoming a more effective tool for raising welfare in many emerging nations asmah and avenue define household welfare as the households control over goods and services available on the market while arouri et al and unnikrishnan and imai define home welfare as the general welfare of members of the household as measured by food and nonfood expenditures and poverty status on the contrary income diversity refers to the process by which households generate a growing variety of sources of income by combining increasingly diverse resources and properties to meet their needs additionally according to wan et al income diversification implies changing the households sources of income several types of agriculture can be engaged in such as production and value addition together with onfarm and offfarm activities can all be leveraged to diversify income income diversity is the circumstance in which a household receives money from sources other than the primary household activity in regard to studies by an estimated 86 percent of the worlds population were living in poverty in 2022 this trend was expected to be more pronounced in the middle east and north africa in addition the unicef research predicted that 16 million people in the middle east and north africa experienced food insecurity in 2021 since march 2020 68 of households in asia latin america and africa have seen a fall in earnings resulting in worse living conditions in addition the percentage of the population living below the poverty line in subsaharan africa was projected to reach 400 percent by 2021 this was an increase from 420 million to 424 million in a period of one year on the african continent the state of affairs is considerably worse as reflected by 28 million south africans receiving assistance as a result of the nations growing poverty and reports suggest that this figure has overtaken that of tax paying citizens making the system unsustainable the east african reports that 29 million people were starving in the east african region additionally consumption expenditure decreased by 30 as income shocks affected 66 percent of ugandan households as of 2020 additionally a study by ubos claims that in the 20192020 survey ugandan household consumption expenditure decreased by 55 theoretically peoples social decisions are rooted in the importance of income diversity and welfare such that the more the income diversity the greater the utility and welfare of the individual and the household the theory expressly claims that raising household and individual income enhances utility and wellbeing furthermore every change in income diversity decisions has a considerable impact on the households welfare families must make decisions on how to diversify their incomes on a daily basis such decisions are unimportant for wealthy families but they could be different for poor families as they are life and death decisions those who do not have enough food will perish as a result of the decision by the households to diversify just as those who do not receive adequate medical care when they are ill will perish mohammed conducted a study to ascertain the impact of income diversification on staff welfare at kaduna state university and found a significant relationship between staff welfare and income diversification in the research area zhao and barry investigated farmlevel variation and its impact on rural household financial status in china they discovered that diversity benefited lowincome rural households while negatively affecting highincome rural households kidane and zegeye showed that income diversity had a beneficial impact on income and reduced susceptibility to poverty in a study to evaluate the effects of income diversification on household well being khan and morrissey investigated how households sources of income changed and discovered that households with more diverse income had lower consumption welfare for instance by allocating a portion of their income to additional income generating activities households can enhance their welfare and end poverty empirical studies of income diversity and household welfare have only measured one component of welfare furthermore the bulk of empirical literature used crosssectional methods which do not reveal changes in welfare over time furthermore previous research findings have proven contradictory there is a substantial association between welfare and income diversity in accordance with empirical research diverse literature has revealed that income diversity has little to no impact on household welfare according to asfaw et al the influence of diversity on household income differs across countries to establish the link between income diversity and welfare the bulk of studies have employed data from mostly developed nations this study attempts to bridge these knowledge gaps and expand the plethora of literature by using two welfare measures and nationally representative panel data from a developing country the study adds to the body of knowledge on household welfare and income diversity in theoretical and practical ways the findings of our study could provide policymakers as well as development partners with critical information about the benefits of income diversity for improving the welfare of households in uganda by incorporating more welfare indicators and explaining how each one relates to income diversity the study theoretically extends the literature on welfare and income diversity the study also offers empirical proof of how income diversity affects household welfare in a developing country like uganda grappling with underprivileged living conditions the remaining portion of this paper is divided into three distinct sections in the first section both the theoretical background and the existing literature on the topic of income diversity and household welfare are discussed the second portion of the paper details the procedures and data used in the study the studys conclusions analyses findings and policy implications are covered in the last part literature review theory of social choice sen an indian economist proposed the theory to explain how individual and household actions affect their welfare the theory specifically states that rising income for households and individuals improves their utility and wellbeing sen observed that individuals actively join families and hence their welfare is dependent on the households collective income therefore the more the household income the greater the welfare the household gains however the welfare of the individual household member is determined by how this income is allocated among the household members if one member of the household has control over the bulk of the resources andor the distribution of those resources the outcome may not be desirable household income diversity leads to greater household income which contributes to poverty reduction and enhanced household welfare a households income fluctuation can be significantly decreased by having a higher level of income diversity in addition to lowering susceptibility to income fluctuations exogenous production shocks and changes in consumption habits income diversification strengthens economic security wan et al also made a proposition on the growing significance of income diversity as a way for households to boost their income and safeguard themselves from risks increases in household wellbeing through loosening consumption restrictions are more likely when household income comes from a variety of sources in other words the welfare of a household is increased when its members come from a wide range of income sources because they can afford to spend more on things like food and other necessities while the welfare of a household from a narrow range of income sources is reduced because of constraints on their capacity to consume food and other items household welfare and income diversity households employ the multipronged strategy of income diversification to reduce their vulnerability to shocks therefore households try to improve their financial situation by obtaining income from a variety of sources kidane and zegeye define income diversity as the contribution of different sources of income as a result the increased resources should improve both consumption and nutrition adepoju and obayelu argue that diversifying sources of income can stabilize household finances generate extra cash for investments and fund the acquisition of hightech farm equipment to boost agricultural output diversification occurs because families want to improve their standard of living by trying new things and adapting to new circumstances profits from income diversification are then used to buy valuable assets and increase the overall worth of the households holdings the number of livelihood activities reduces the danger of low income production from a single issn 26895080 volume 6 issue 2 2023 125 article doi 1052589ajesdytbgwcwg doi url investment in poor conditions which enhances the households revenue from diverse incomegenerating activities households with a varied portfolio outperform those without as a result diversified households are more likely than nondiversified households to spend more on consumption and asset accumulation at the end of the year or period furthermore diversified income provides lowincome households with a major financial advantage that is growing the theory is consistent with empirical findings linking household welfare and diversified income financial difficulties can be overcome by a household with diversified income income diversification may increase household spending by reducing economic insecurity in other words as income diversity increases household income they spend more a higher household income leads to increased savings that are then invested in durable household commodities increasing the value of the households holdings income diversification promotes welfare by minimizing a households dependence on just one source of income households spread their investments to reduce risk as well as increase income and eradicate poverty the protection against reductions in demand and price variations comes from additional incomegenerating activities in supposition households will experience increased welfare if they diversify their income sources it follows that households that do so perform better than those who do not there have been many studies done on the effects of different incomes on household welfare for instance zakaria et al evaluated the effect of livelihood diversification on farm welfare in ghana using a multiplestage sampling strategy a probit model and the propensity score matching method according to the study farmers who were older had access to extension services were men and thought that rainfall was inconsistent and temperatures were high were more likely to diversify their crops additionally they discovered that households on farms with diversity outperformed those without it similarly xu discovered that income diversification increases consumption among chinese peasants in the countryside using panel data collected at the provincial level between 1998 and 2015 the study found that while peasant consumption is less responsive to income diversification in the provinces with intermediate income it is more responsive in the provinces low income as well as high income subsamples respectively stifel used data from madagascar that were considered to be nationally representative in order to study the relationship between rural nonfarm employment and household welfare the research which made use of multinomial logit models came to the conclusion that highreturn nonfarm activities can provide an essential route out of poverty using data from the bhutan living standard survey conducted in 2012 rahut et al conducted an analysis to determine which options for rural diversification of livelihoods were most beneficial to the wellbeing of households propensity score matching was used to estimate the parameters they came to the conclusion that diversification of household income into nonagriculture businesses was influenced by a variety of characteristics including education level amount of assets owned accessibility of labor and the gender of the person who headed the household they also discovered that rural households that diversified their sources of income beyond agriculture have better incomes and lower poverty rates than those rural households that only have farms and that doing so can help significantly cut poverty rates hong et al investigated the relationship between having many sources of income and the welfare of households the survey data they used came exclusively from china in addition they discovered that farm households that use strategies for income diversification have higher rates of forestry agricultural offfarm consumption and savings than those that do not in addition to a decreased risk of experiencing relative poverty this was found in comparison to households that did not adopt such strategies on the other hand ebenezer and abbyssinia examined the impact of livelihood diversification on welfare using south african data they found that the households in the province were homogeneous using the tobit regression model and a modified multidimensional poverty index access to electricity agricultural participation asset score total income and location have all been linked to household poverty all of these factors had an impact on poverty in the province furthermore gautam and andersen used household survey data to create a composite household welfare score which they used to investigate the effect of livelihood diversification on nepalese welfare their findings revealed a recurring trend of diversity in the types of jobs undertaken for compensation as well as a wide spectrum of household wellbeing they also discovered that variety had no effect on happiness it has also been shown that diversifying ones livelihood has a skewed effect resulting in differences in income and welfare the number of income sources accessible to rural families as well as the impact of different income sources to total income and wellbeing were also evaluated by omotesho et al using primary data the study demonstrated a negative correlation between the number of income sources and the households livelihood status for the lower the livelihood status the more diverse the households income in a panel study mendoza developed a twostage pooling and fixed effects model to examine the filipino household income diversification behavior the study found that risk aversion and wealth accumulation were the main drivers of income diversification the study also came to the conclusion that diversity helps wealthy families reduce future income and consumption swings with no data suggesting that diversification has any impact on rural households whose diversification strategy is mostly motivated by subsistence based on these justifications we thus hypothesize h1 income diversity has a major impact on household welfare data and methods data the uganda bureau of statistics provided secondary data that were used to generate the findings of the study which was quantitative and panel in nature to determine the study hypothesis we collected data from four waves of the uganda national panel survey which was collected between 2013 and 2020 measurement of variables there is no single indicator that can be used to assess household welfare consumer expenditure and poverty status are utilized as the studys key measures of household welfare consumption expenditure is widely used because it is less susceptible to seasonal variability and other shortcomings than other welfare indicators the total annual consumption expenditures for the household were calculated in uganda shillings additionally poverty status was chosen because according to nguyen et al a households poverty status is a good indicator of its standard of living poverty status which is measured as an integer variable using pov1 if a households income exceeded the poverty line and pov0 otherwise is the likelihood that a household could not meet its basic necessities when a household has various sources of income in addition to its main source of income this is referred to as having diversified income in this study income diversity is represented through passive income sources as a continuous variable the variable was measured in uganda shillings econometric estimation according to newman et al the traditional panel model was used to study the relationship between income diversification and household welfare the measurement of the welfare of households as proxy variables thus dictated the empirical kinds of the panel models used in this paper for instance consumption expenditure of the household was measured using a continuous variable … … … … … … … … … … … … … … … … … … … … … … … 31 since consumption expenditure is used as a proxy for household welfare in the following analysis we develop an econometric random effects panel model … … … … … … … … … … … … … … … … … … … … … 32 the probit regression model was used to specify the statistical form of the empirical panel model where household welfare serves as a qualitative proxy for poverty status 𝑃 𝑖 𝐸 𝜑 were categorized as poor as a result table 2s descriptive statistics show that on average households in the four waves under consideration had a poverty rate of roughly 14 according to the descriptive statistics in table 3 the mean annual household diversified income across the four waves under investigation was about uganda shillings two hundred and eightytwo thousand the 20192020 unps wave had the highest mean annual household diversified income of roughly over one million while the 20132014 wave had the lowest mean annual household diversified income of around one hundred and thirtyseven thousand the descriptive statistics on diversified mean annual household income demonstrate significant variations in household diversified incomes among the four unps waves with an overall standard deviation of roughly uganda shillings one million the results of the jarquebera test for normality are displayed in table 6 and the coefficient of chisquare and associated pvalue are not statistically significant therefore the results of the test do not contradict the hypothesis that logconsexp fits a normal distribution diagnostic tests the influence of diverse income on consumption expenditure the endogeneity concerns of the independent variables due to measurement errors are addressed by employing two estimators in the panel regression with the quantitative dependent variable the twostage leastsquares within estimator for fixed effects and the twostage leastsquares randomeffects estimator for random effects both of these estimators are instrumental variable estimators we estimate the models using robust standard errors to control for heteroscedasticity and withinpanel serial correlation in the idiosyncratic error term to determine household welfare the logarithm of household consumption expenditure was utilized table 7 displays the summary regression estimates for models 1 and 2 when applied to the null hypothesis that the random effects estimator is the preferred model the computed hausman chisquare statistic overwhelmingly rejects the null hypothesis in favor of the alternative hypothesis according to the outcomes of the hausman test the individuallevel effects in this study are best fit by a fixedeffects model as a result the estimates from the fixed effects model are the focus of discussion when interpreting the results estimates for income diversity in table 7 are positive and statistically significant at the 5 level based on regression estimates from models 1 and 2 results demonstrate that using consumption expenditure as a proxy for household welfare a one percent increase in the households diversified income improves household welfare by around 33 percent assuming all other parameters remain constant table 7 demonstrates that living in an urban region as opposed to a rural location the head of the households age the size of the household all have significant effects on the households welfare according to table 7 a higher welfare is associated with a higher level of education an older household head a larger family an urban rather than rural location and employment in the service sector the effect of income disparity on the prevalence of poverty for the panel model with a binary outcome variable the study employs the panel probit model the probit model was analyzed as an instrumental variable model to handle endogeneity in the explanatory variable the summary regression estimates for model 3 are shown in table 8 this model uses the household head poverty level as a surrogate for household welfare table 8 estimates household size whether a household is urban as opposed to rural whether a household is located in the eastern area and whether a household is located in the northern region table 8s estimates show that variables assumed to have no effect on the estimated risk of household poverty have 5 significant coefficients only in very few cases such control factors include the gender of the household head the marital status of the head of the household the industry in which the head of the households work is performed and whether the household is located in the western or central regions estimated results indicate that income diversity is a crucial factor in establishing household welfare in addition both the ivfixed effects and ivprobit estimates demonstrate that households can benefit from income diversification the financial security of a household can be enhanced by diversifying and periodically reinvesting the income stream income from multiple household sources including but not limited to informal agriculture revenue and official nonfarm income are used in this study the study showed that a positive and statistically significant anticipated coefficient for the variable of diversified income was observed since the estimated value of the diversified income variable agreed with the a priori hypotheses of the study it was deemed theoretically valid and statistically reliable consequently the null hypothesis that income diversity does not affect household welfare in uganda was incorrect instead the regressions in this study showed that increasing household income diversity significantly increased household welfare the portfolio diversification of household incomes as represented by the diversified household income is more evidence of the societal paradigm shift their research showed that when household income was diversified vulnerability and poverty decreased the head of the households level of education was reported in terms of completed years of schooling consistent with our a priori theoretical expectations we found that a positive and statistically significant coefficient on the education variable in the ivfixed effects model and a negative and statistically significant coefficient on the education variable in the ivprobit model were associated with a higher level of household welfare the likelihood that a household will enjoy better welfare standards is increased when the household head has a higher level of education this is because individuals with a higher level of education are more likely to find gainful employment to be able to provide for their families basic needs and to have access to longterm support this may provide light on the correlation between the level of education of the households head and its financial wellbeing according to the categorical variable region in the empirical model two of the three categories included significantly impacted household welfare four categories were created for this variable with central region serving as the reference category the studys estimations show that households in the eastern and northern regions experienced a considerable decline in welfare compared to households in the central region northern and eastern uganda have higher poverty rates which may explain this the rates of chronic poverty were highest in the north then in the east and lowest in the center according to ubos these regional differences in poverty were discovered between the uganda national household survey periods of 201516 and 201920 the capital of uganda kampala is also situated in the countrys central area giving household heads easier access to utilities better employment possibilities and opportunity to engage in profitable economic activities summary and implications using panel data from the most recent four waves of the uganda national panel surveys this article examines how household welfare affects income diversity in uganda the study employed consumption expenditure and poverty status as surrogates for household welfare three types of estimators were utilized to construct the empirical panel models the fixed effects of the instrumental variables the random effects of the instrumental variables and the ivprobit model however the proposed ivfe and ivlogit regressions formed the basis for the final models predictions according to regression estimates income diversity has a considerable impact on household welfare as a result variations in the households diverse income can be used to account for changes in household welfare further research found that the degree of education of household heads as well as whether they resided in the central eastern or northern zones might have a significant good or negative impact on the welfare of households the studys findings show that greater participation at home activities can improve household welfare by broadening access to several sources of income this suggests that households whose primary means of economic support is engaged in productive rather than passive economic activity are more likely to enjoy financial success and it is possible that household welfare would improve if people moved away from primary economic activities like subsistence farming and toward secondary economic activities like manufacturing and services study limitations and future research directions despite the current studys contributions further research is still needed to fill in the gaps the research model used was unable to adequately describe how subjective welfare is future studies may consider taking a pragmatic approach this could lead to the use of both primary and secondary data for that purpose

the study aims to investigate the empirical relationship between household welfare and income diversity we examine the effects of potential endogeneity brought on by selection bias using instrumental variable static panel model regression the uganda national panel survey waves were used in the study the results demonstrate that having a variety of sources of income significantly improves household welfare the findings further revealed that household welfare is significantly predicted by the household heads education while living in the eastern or northern regions has a negative effect on welfare relative to living in the central region the methods employed in this research were unable to adequately describe the subjective nature of welfare future studies may consider taking a pragmatic approach the utilization of both primary and secondary data for further research may reveal amazing results in contrast to past research that only used expenditure as a proxy for welfare the research study advances the literature on welfare by demonstrating the impact of income diversity on household welfare as measured by poverty status and consumption expenditure the study extends the welfare theory by showing how diversity of income enhances household welfare using a sample of households in uganda a developing economy

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introduction topical introduction and status quo croatia is a popular tourist destination and not just since and because of winning the viceworld football championship in 2018 a sober look at the related figures from the international monetary fund reveals an obvious trend croatia indicates further expansion in recent years gdp has risen steadily and at first sight has made a pleasing picture over the next five years the forecasts of the imf even intend croatia to grow faster than germany the heavyweight member of the european union if you look at the increased number of overnight stays and the number of tourists in croatia in the last five years it is obvious tourism is proven as a means of promoting economic growth and makes a big contribution to the gdp but this must not hide the fact that the country is exposed to a few structural problems • the largest trading company in the countryformer agrokor group with 40000 jobs and 15 of gdp undergoes a major restructuring process • the uljanik shipyard in pula has been declared bankrupt in the meantime • the national debt of the country has been rising for yearsnow 75 • the unemployment rate only just into the doubledigit percentage range and • the average wage is far below the eu averagegross hourly earning 5 eur compared to eu28 13 eur looking at these key figures evokes questions so the tourism sector is in great demand as it is characterised as the main supporting pillar of future growth a deeper investigation of the croatian tourism situation is therefore essential in order to provide a more detailed insight into the correlation between tourism and gdp the authors talked to tourism industry officials to obtain their personal assessment and experiences by using expert interviews further problems to discuss are • is this a country that rests on its tourism laurels • what do the experts think regarding this question and future challenges as an extended introduction it should not go unmentioned that the reference country croatia is not only shown in an isolated space but that the study also offers comparative features different countries were discussed which deserve to be categorised as holiday destinations and offer links of various types to the reference country this also qualifies the view of delhey and kohler whose statements are presented in a contextsensitive manner specifically in the sense that the focus on certain model societies often has historical and cultural reasons the neighbouring and holiday country montenegro could be considered as a reference country because of its similar climatic conditions and culture hungary could be used as a benchmark for historical reasons with regard to the former union of states and the subsequent division of sovereignty with balaton being a popular destination for international tourists for most european countries spain for example is the reference country in the competition for tourists for the introductory context however germany is of interest to the authors as a reference country germany is becoming increasingly popular as a travel destination for international tourists especially since the german tourism industry has been one of the most flourishing and highestturnover sectors of the economy for years nonetheless we chose germany as the reference country because of its economic stability as it is the largest economy in the european union since the focus is on the comparison of gdp indicators here germany is traditionally considered the leader or benchmark country research question discussions concerning the competitiveness and future sustainability of the croatian tourism sector are certainly not new the authors want to deepen them reflecting on the above object of investigation the researchleading question is articulated as follows what does a sober look at the tourism situation in croatia look like how do experts judge it and what challenges have to be mastered in the future the experts were selected through personal and professional contacts they are based in the tourism industry in principle expert knowledge is not necessarily associated with a status profession or even prominent position within a company or organisation however one can generally assume that questions including our research question which deal with the future development of an industry are always of a strategic character positions at higher hierarchical levels are more likely to be involved in such issues than employees in the operative area or lower hierarchical levels as a result we have specifically focused on interview partners from the management level in this context we would like to briefly point out that the possible questioning of other market participants for example tourism managers abroad or management consultants would probably also have led to interesting findings however we deliberately did not carry this out as the depth of knowledge of the croatian market in the first case tends to be lower than that of local industry representatives in the second case mentioned we assumed that their expert knowledge would ultimately also be based on surveys so that we want to refer to primary sources or surveys in our work independently the data collection or sampling was targeted since the aim was to obtain important information for answering the research question the aim was to gather as much information as possible in order to identify factors that point the way forward the customer proximity with the associated feedback is the key criterion for us to put it simply tourism managers have the practical background and are most likely to know how their industry ticks and are also familiar with the specifics of their industry methodological approach the research question will be further investigated in the expert interviews in chapter 3 in addition to the statistical analysis and the literature analysis the future competitiveness of croatia is critically examined in an essential step through guidebased interviews with 10 experts the experts were asked how they assessed the current situation in the croatian tourism sector furthermore their own suggestions for improvements in the future were noted during the survey or research process we followed the theoretical sampling with regard to the number of interview partners here data collection and analysis took place simultaneously so that the findings of previous interviews were leading to the selection of the next ones at a certain point a theoretical saturation occurs the sampling is then finished when the further cases and analyses do not provide any new insights such a saturation point eventually occurred for us after 10 interviews as the central themes were repeated in the interviewees answers economic indicators gdp in order to examine the current economic situation of the country in more detail some economic data have been subjected to a comparison the following tables and graphs are mainly based on data and documents from the international monetary fund and show firstly the croatian gdp in global comparison what does this comparison express evidently and according to the imf the country expects eight times more growth in the next five years than in the last nine years between the lines high expectations are attached to the small country such an expectation cannot be recognised in any of the other illustrated comparative countries or groups of countries a further comparison can be clearly evident in the following graphs in which historical as well as future data between the small croatia and the eu heavyweight germany are more intensively illustrated the graphs clearly illustrate that the small country has to compete with the big ones in terms of its development and future expectations after the subprime crisis the gdp in germany suffered slightly and fell by 12 between 2010 and 2015 before rising by 172 until april 2019 for croatia it looked more dramatic gdp fell by 173 from 2010 to 2015 but increased disproportionately by 237 from 2015 to april 2019 in the future forecasts too the croatian expectations exceed the german ones the comparison of the data and graphics impressively illustrates how contrarily the future prognoses of populations can degenerate while the first three groups are all associated with rising and germany with stable forecasts the croatian population trend is retroactive it should not be forgotten that in the previous gdp graph the croatian curve is reciprocally based on a rising trend in the future both these graphics show the past and future development in a transparent and characteristic way a stable population in germany with simultaneous loss of people in croatia the population of germany increases by 33 from 2010 to 2020 and that of croatia decreases by 86 here it is made clear between the lines that the country offers too little incentive for the current inhabitants to remain loyal to the country permanently figure 2 graphical timeline for the development of gdp in germany population gdp per capita croatia figure 7 graphical timeline for the development of gdp per capita of the groups mentioned above in the period from 1980 to 2024 source international monetary fund 2019 visually this is the only image in which the trend of all curves is correlated or at least similar it can even be seen that croatia is on an aboveaverage course here tourism share number of tourists and overnight stays figure 9 number of tourists over time source tourism ministry of the republic of croatia 20102019 figure 10 number of overnight stays over time source croatian bureau of statistics 2019 all three graphs clearly prove that tourism in croatia is developing in the direction of an economic miracle they correlate with each other and show the same inclination shares of gdpdevelopment this subchapter deals with domestic distribution in the context of gdp due to the tourist trend statements and developments illustrated in the previous chapters there should be no overdimensioned surprise findings if one looks at the temporal track of the gdp components in detail the following survey is part of a study by the university of zagreb which impressively demonstrates how the services sector has grown in the last 20 years notes gdp gross domestic product source authors own calculation when you look at the graphics little can be added it almost creates a cautious impression of how the previously important agricultural and industrial sectors are now visibly affected how the development of tourism performance is judged by experts will be questioned in the next chapters it will become apparent during the course of the study that the tourism sector could be the saviour in distress investigations procedure problem solving process this chapter examines the extent to which the first findings and impressions in the previous chapters are reflected in the opinions of experts in addition the survey of the industry experts offers the opportunity to obtain estimates that were not or were only insufficiently available in the literature this considers eg the question of the countrys current position choice of the methodresearch design the following explanation of the research design follows a transparent presentation of how the respective empirical data was collected and analysed and how the empirical research interest was answered this includes sketching in each case the survey method the procedure and the evaluation method in a short form the choice of the survey method fell to the nonstandard interview which belongs to the field of qualitative social research in this interview form neither the questions nor the answers of the interview partner are standardised the subtype guide interview focuses on a given topic and on a list of questions the guide in the question formulations and the sequence of questions however there is no liability and it allows the interview partners as natural a conversation as possible the guideline is intended to ensure that all relevant aspects of the research subject are addressed with the support of such guideline interviews selected experts on the topic were consulted and directly interviewed for this work the term expert is to be understood in the sense of a group of persons who have a special knowledge in the soughtafter matter and pass it on request guided interviews can be in person by phone or in writing for this investigation the interviews were conducted partly in person partly by telephone or by email and recorded with the agreement of the interview partners using a digital recording device chosen circle the classification into an expert group was based in particular on the basic idea that the interviewee should either have many years of responsible management experience in the hotel or tourism sector or the person has been working in the tourism higher education sector for many years in context with the expert interview we understand a 10year rule as a central element of expert competence according to which it takes about 10 years of experience to acquire expert competence the average professional experience of the interviewees was well over 10 years furthermore the respective positions underpin the high requirement profile which is generally indicated by correspondingly long and relevant professional experience for the type and quality of information obtained through empirical research the choice of interviewees is an elementary influencing factor for the present work it was therefore relevant to examine the topic not only from purely technical expertise but also from the perspective of all main regions of croatia dalmatia istria slavonia and zagorje the consideration of all these main regions should not lead to an unbalanced result the profiles of the respondents are as follows • the chosen experts are mainly longtime executives in the tourism sector • have academic and high professional backgrounds • have an average of 20 years of experience in the tourism field per person • have an overall achievement of over 500000 overnight stays annually • essentially directors of hotels and croatian tourist national boards professors in tourism president of county chamber of commerce and furthermore one university chair holder and • eight persons interviewed in the coastal cities and two in the inland area of the country another criterion for selection was the time availability of the experts during the study period and their willingness to cooperate in this research project interview questions for the purposes of this research the authors perceived it necessary to ask different experts the same questions in order to compare different opinions and answers in a meaningful way before conducting the interviews it had to be clarified who should be included as an expert the interviewer deliberately selected the participants as they were known to him and had relevant knowledge about individual aspects of the subject matter a random sample of the interview partners would therefore have made little sense in this respect certain persons were to be interviewed since they could be assessed as particularly relevant and capable of providing information based on their own insights into the subject of the study in the first half of the questionnaire care was taken to ensure that an adequate presentation of the experts was guaranteed the second half of the questionnaire focused on the operationalisation of the research subject it was emphasised that the questions were open neutral simple and clearly formulated although it was reasonable to suppose that the experts to be interviewed would all have only a short time for such an interview no time limit was set for the purposes of loosening up the interview situation relevant literature suggests that between eight and fifteen questions are required to answer such a complex topic accordingly the interview guide consisted of thirteen questions the guide began with introductory questions for the purposes of presenting the interlocutors which allowed a more relaxed mood in the beginning in addition to the name position and company this also included professional experience along with tourist key figures table 5 introductory questions of the guide interview 1 first let us know something about you what is your name academic background position held and company 2 how many years of experience do you have in the field of tourism 3 3 how many tourist capacities does your company run 4 how many overnight stays does your company achievesell and where are the majority of guests from 5 what means of transport do the majority of guests arrive by source authors own guide interview creation hereafter follows a section with questions about the contents sought and goals of the tourism object of investigation in addition to the current practical relevance of the topic and including ideas of competition with other countries respondents were asked what points they would like to change in the future in terms of the tourism situation in croatia table 6 professional oriented questions of the guide interview main results preliminary explanation of the result evaluations for a detailed evaluation of the interview results the literal transcription was selected this elaborate method is particularly suitable for relieving the interviewer from logging during the interview and concentrating fully on the leadership of the interview the interviews were recorded using a digital recording device depending on the approval and the meeting of the interviewees in the subsequent transcription of the interviews standard orthography was chosen speech pauses nonverbal utterances such as throat clearing stuttering and filler words in the transcription were ignored and partially adjusted in the way that the sentence structure was smoothed and the font english was adjusted similarly introductory words interview explanations or small talk at the beginning and end of the interviews were not transcribed for capacity reasons and lack of relevance to the content of the interview the qualitative survey method used conscientiously follows the principle of openness this produces a significant amount of blurred raw data to be evaluated therefore a suitable qualitative evaluation method must be chosen the chosen method of qualitative content analysis enables an evaluation of complex material in a systematic and methodically controlled manner without freely interpreting it or losing information through rigid systematisation such as in quantitative content analysis following a systematic procedure the texts were extracted from information that was then assigned to a category system and further processed independently of the source text in this way and according to the purpose of the study the wealth of information was systematically reduced and structured the following subchapters focus on the presentation of the results of the expert interviews these would be used to answer the research question the presentation of results is based firstly on an antithetic discussion in the form of positive and negative aspects as well as two analysis techniques according to mayring summary the aim of the analysis is to reduce the material so that the essential content is retained to create a manageable corpus through abstraction which is still an image of the basic material and structuring the aim of the analysis is to filter certain aspects out of the material to lay a crosssection through the material according to predetermined order criteria or to assess the material based on certain criteria in order to give the insights gained an authentic perspective a list of the interview statements mentioned above was to be incorporated into the presentations in the process various parallels were revealed in the main statements as the following explanations will show positive aspects the positive aspects of the investigation could be preceded by the following points listed according to the number of mentions a preserved untouched nature mediterranean natural beauty b beautiful adriatic sea c domestic and ecologically grown mediterranean food d heritage tourism e preserved culture and religious heritage f general safety g constant upgrades in tourism infrastructure in the following the abovementioned positive aspects are explained in detail and in parts by way of example explanation of the survey results a preserved untouched nature mediterranean natural beauty b beautiful adriatic sea croatia is widely known for its natural beauty and crystalclear adriatic sea it is influenced by ideal sea currents and a mild mediterranean climate the incredible diversity of the landscape of croatia will leave a lasting impression on everyone with its national parks forests sea caves and more than a thousand islands croatia is truly beautiful also on various international tourism sites one can find descriptions which position croatia in the european countries comparison front exemplary statements in a brochure are as follows from ancient walled towns to gorgeous beaches framed by sparkling blue waters theres nothing you cant find in croatia a land of great natural beauty and astounding cultural heritage although modest in size the small central european country abounds in notable historic sites and national parks packed with dense forests striking waterfalls and unbelievably beautiful lakes two such places are the breathtaking plitvice lakes and the unique kornati archipelago with its 140 pristine islands surrounded by crystalclear azure seas c domestic and ecologically grown mediterranean food what distinguishes croatia from other european countries are its famous gastronomic delicacies from fish at the seaside to meat specialties on the continent besides standard european cuisine croatia also offers its most popular local dishes and specialities in dalmatia and istria the main dishes are fish and seafood and in the continental part there are meat specialties not only the beautiful beaches but the sea and sights are also widely illustrated on tourism websites there are even separate pages that focus on the various traditional delicacies and are articulated as follows as with every country that is culturally historically and geographically as diverse as croatia its cuisine can hardly be pinpointed to only one type over the course of time and the historical impact of other nations a wide range of nowcalled traditional croatian dishes developed in different parts of the country the continental cuisine of croatia for example under the influence of the austrian and hungarian hegemony is mostly based on meat dishes and vegetables that are often served in rich and spicy sauces the traditional coastal cuisine is on the other hand mostly based on seafood domestic olive oil and vegetables like chard inevitable condiments that give this croatian food its unforgettable taste are rosemary basil and other mediterranean herbs dalmatian and istrian dishes are not only light and healthy but also extremely delicious although sometimes similar to the cuisine of the neighbouring mediterranean countries the coastal cuisine of croatia has many dishes that are unique only to this geographical region d heritage tourism e preserved culture and religious heritage as can be seen in the list below croatia is a country with numerous cultural and natural heritages under the protection of unesco croatia has been an equal member of unesco since its independence from yugoslavia on 25 th june 1991 and its preserved culture and religious heritage were included as such under the unesco statutes the corresponding universal codification can be found in the conventions on the unesco website the general park f general safety this point describes another advantage for the country this can also be seen in the published article by simmonds he noted a general lamentation at a high level of the population but at the same time emphasised the everyday security benefits while everyone complains about some aspect of life or another here in croatia the reality is that the safety levels are excellent your kids can easily be left to play on their own like back in the good old days in other countries and in many aspects its as if time has stood still the majority of crime here is traffic crime rarely does anything major occur g constant upgrades in tourism infrastructure investments are constantly being made in the development of the infrastructure in the republic of croatia the reason for this is the pronounced seasonality of tourism when the number of inhabitants in many tourist destinations repeatedly exceeds their number in comparison with the offseason period the summer months present a major challenge in terms of infrastructure especially for the cities of dubrovnik split and even the islands specifically major construction projects partly cofinanced by the eu are in progress here these include among others the construction of the pelješac bridge opening of a new terminal at zagreb international airport reconstruction of the croatian road network railway construction and the clean water project negative aspects and change requests of course while a number of positive effects have been found in the study it is important not to ignore the negative comments and utterances that were mentioned a longterm strategy not really recognisable b current tourism infrastructure c priceperformance ratio questionable d sun and sea concept not enough for long competitive advantage explanation of the survey results a longterm strategy not really recognisable croatian tourism primarily in coastal parts continental part neglected it is a wellknown fact that tourism in croatia mainly takes place on the coast furthermore the respondents stated that it is no surprise that the authorities have neglected continental croatia in addition statistics show that up to 86 of the total number of overnight stays throughout the year are realised in the summer months therefore it is not surprising that the biggest croatian tourism investments are in the adriaticcoastal area and not the continental area however one must not forget that the country had to master great challenges due to its recent history and the difficult conditions created by the consequences of the homeland war in addition there were insufficient privatisation models that were not always useful for the tourism business nevertheless tourism has managed to establish itself and yet benefit from great foreign interest as the ministry of tourism of the republic of croatia has recognised … croatian tourism still managed to show its vitality thanks to the strength and interest of the international market the attractiveness of the country and most of all the resilience of tourism as a reaction to occasional global events when it comes to mass tourism the economic benefits seem to outweigh at first glance foreign exchange inflows or activities of general and special socioeconomic interest nonetheless the negative aspects which are concretised in attributes such as seasonal character spatial concentration and the distribution of tourism must not be ignored this problem must be relativised and channelled one of the most important factors in measuring tourism success is the measurement of the intensity of tourism seasonality in a given country the intensity of the seasonality of croatian tourism is 60 and takes place in three summer months the following key figures based on the climatic conditions cannot be ignored as a rule the tourist offer has a seasonal character which means that it is not used in the same intensity in all seasons the basic determinant that characterises individual seasons is the climatic factor which as a rule forms the two major tourist seasons b current tourism infrastructure only partially meets the needs of tourism development only the following cited sentence of the croatian minister of tourism meets the above point very aptly reaching 20 million tourists and 100 million nights with our infrastructure is our maximum croatia needs to develop the preand postseasons and to raise the quality as mentioned in the earlier text croatia has announced plans for a new investment in tourism infrastructure especially in the transport infrastructure with an amount of 20 billion kunas the main reasons are the high expectations regarding the quality of tourism offers four and fivestar hotels have been key factors to croatian success with tourists who are attracted by high levels of quality according to the ministry of tourism there has been a 70 per cent increase in the number of four and fivestar hotels in recent years while the share of threestar accommodation has been reduced from 42 to 34 per cent higher quality accommodation as well as a proper infrastructure will continue to be in demand in the future and there is no way around it c priceperformance ratio questionable tourists could move to a more competitive destination if the service quality gets worse the following overview impressively underlines in this sixcountry comparison the priceperformance ratio of the country in question in which the price trend of croatia over other countries is glaringly obvious figure 11 priceperformance ratio source pavlic v 2019 prices for tourism services when considering croatia are often questioned tourism is a branch of the economy that is highly vulnerable to external influences and to the international market all the abovementioned mediterranean countries have strengthened their competitiveness with strong promotional and marketing activities by hoteliers and tourist boards in croatia prices are rising so fast that the price performance ratio is debatable with such a percentage increase in price guests expect the content and the quality to correlate with it that may be called into question d sun and sea concept not enough for long competitive advantage in the 1970s when tourism in croatia took shape the sun and the sea were the main assets for attracting tourists today almost half a century later this concept is no longer sufficient as tourists are increasingly looking for additional facilities and active vacations the sun and sea concept is not new of course and researchers take that as a starting point in a critical context even though mediterranean countries have a lot to offer in terms of historical and cultural heritage most tourists visit them to enjoy a warm climate and the coastal natural attractions the question is whether it will survive in the international comparison in the long term of course this question cannot be answered without this and that but at least in part it has to be examined and evaluated in its basic totality and that includes examining its disadvantages it is geographically concentrated along the coast which generates congestion costs and feeds regional imbalances moreover nowhere in the eu does tourism show such a strong seasonal profile as in croatia category system as a further instrument of content analysis work according to gläser and laudel the category system serves for a more appropriate extraction of the relevant information from the expert interviews it builds on the preliminary considerations and questions of previous chapters and thereby ensures that the information extraction is guided by the preliminary considerations in this chapter the content analysis mentioned is carried out in a slimmeddown version since the antithetical discussion presented already offered a broad information radius from all interview results the actual intention of this chapter is to further condense the core contents of the interview results and to divide them into main categories in order to address the research question in a further dimension the authors have developed three main themes for the category system which are incorporated into the corpus of the study as empirical core elements a tourist perspective of the country the majority of the interviewed experts evaluate croatia as a country with mediterranean unspoiled beauty which includes in particular the beautiful adriatic sea in addition the domestic and ecologically cultivated or mediterranean food products including wines also stand out another reason given for the special position of the country is that security aspects are more in the focus of interest today than ever this operational importance of general security brings obvious advantages to the country also due to its entry into the eu when compared to other holiday destinations this is not a fundamental reorientation in the tourism industry but as a result of global unrest and terrorist attacks this point is more important than ever and can be categorised as a possible delimitation feature b current challenges basically the perspective of the experts was transferred from the positive argument to a critically oriented position various points and suggestions emerged in which the experts not only saw potential for improvement but rather an urgent need for action first of all there is talk of a lack of manpower that cannot be managed this is closely related to the tax dissatisfaction of the tourism companies who would use the desired tax relief directly to recruit better staff the majority of the experts not only criticise this point from the theoretical aspect but it became clear that they are confronted with it also in their daily practice they argue that such an implementation could sustainably improve the level of education and the salary conditions in the hotel industry c sustainability and future strategies the last category sustainability and future strategies deals with the extent to which the tourism industry in croatia can persist in the european tourism market and which strategies would be necessary critical and positive statements in the results of the expert interviews roughly balance each other out however what remains according to some respondents is the lack of specification of longterm strategies that affect croatian tourism on the one hand this includes the perception that the current tourism infrastructure only partially meets the needs of tourism development on the other the insight that the country is still competitive but that it has to continuously improve the quality and the offer for guests one of the key insights gained from the work can also be seen here because according to the current development the competition is not sleeping and the high price level of the country could make cheaper countries like albania more attractive in the future namely albania introduced a number of tax measures to attract foreign investors in the hotel industry domestic economic problems such as the rapidly increasing employment of foreign forces from serbia and the simultaneous emigration of the croatian population certainly do not make the perspective in the overall context any easier conclusion and outlook the research above has shown a differentiated picture of the tourist situation in croatia the sunny side of the country with certain emphasis is obvious the negative aspects have been developed on the basis of a qualitative content analysis of the respondents the ten expert interviews with proven experts build on the preliminary considerations and initial findings from chapter 2 and on the questions derived in the initial chapter the practical point of view was quickly adopted and the reference country croatia was examined in perspective the influencing factors already described and presented in theory chapter 2 were also largely consistent in the results as a result the change requests of the interviewees were particularly striking they affected the economic indicators of the country and expressed their desire for corresponding measures change requests • tax policy using it for wage growth and subsidies for regarding offseason work • more vocational education raise early education and specialisation in gastronomy hospitality and tourism • subsidies extension of measures for the development of continental part • maintenance regarding numerous tourist facilities that are empty and rugged and owned by the state • focus on development strategies there is initially a great disappointment among entrepreneurs in terms of tax aspects and lack of subsidies it also calls into question educational policies that do not stand up to the current demands of the tourism sector this automatically results in requirements and wishes for the future that are expressed and addressed as future aspects and challenges within the study • lack of labour force big future problem • missing vocational training in tourism areas gastronomy staff insufficiently educated and trained for high level service • seasonal employment through imported labour from neighbouring countries government should intervene • salaries are not enough for young people from croatia government should help with subsidies for working in postseason and retention of young people • lack of quality staff approaches slowly the domain of chaos each tourist worker is the mirror of the achieved standard of destination and a decisive element of sustainable tourism educating employees at all levels can bring a better perspective as seen from the results of our research the biggest challenge for croatian tourism is the lack of quality and educated workforce croatias labour market capacity is certainly not enough and the country will have to turn increasingly to attracting foreign workers from eastern european countries and beyond there are profound points of argument which give their attitude to the preceding remarks as kotler bowen and makens state employees value working in wellrun organisations that offer high quality products receptionists do not like to receive guest complaints the costs of poor quality include absence fluctuation and employee morale … researchers have compiled a list of reasons recently cited by students of hotel and restaurant management schools as reasons for dismissal one of the reasons they cited was a lack of quality in the organisation when an organisation has good quality it can retain good employees recruitment is easier and training costs are reduced the transparently pointed out and cited problem reflects poor pay levels poor education and skills in a still predominantly stateowned economy which has led many young croats according to analysts to find more lucrative and efficient work in wealthy western eu countries recent developments show that at least 30000 jobs in the country mainly in tourism are vacant and that there are also deficits in the construction and manufacturing industries this also impedes the hope of catching up with colleagues in the european union this shows that there is potential not only in the qualitative area but also in the quantitative area in the economic context of the country closely connected and overlapping is the challenge that ilic implements this at a time when croatia and other european mediterranean tourist hotspots are struggling to cope with huge crowds arriving on cheap flights and cruise ships in the summer high season in conclusion the importance and advantages of the tourism sector are undisputed for croatia what is more disadvantageous are its characteristics which have displaced the other areas of the gross domestic product proper industry and agriculture which together accounted for the majority of the gdp 30 years ago are now looking extinct whether this imbalance can be equalised is considered unlikely however the tourism sector should at least be more focused on sustainability so that its potential is not limited to three months of the year because cultural heritage and the beautiful nature could also be used in the other months for tourism or otherwise

despite structural problems croatia indicates further expansion the trend of increasing gdp has continued in recent years the tourism sector significantly contributes to this development to give a more detailed insight into this the authors spoke to tourism industry officials to obtain their assessment and experiences via expert interviews the methodological approach chosen from qualitative social research aims to identify future challenges strengths and weaknesses for the croatian tourism sector and to make recommendations preliminary results seem to suggest that despite the increased tourist numbers there is doubt as to whether croatia´s tourism industry will be able to stay competitive with other countries in the future clear strategic planning is one of the weaknesses of economic indicators such as a lack of qualified personnel or tax policy imbalances the work aims to provide a contribution to the empirical research of croatian tourism and to advance findings in the geospatial field of future challenges sustainability aspects also play an important role in making the country fit for the future

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background there is growing evidence of the impact of overweight and obesity on shortand longterm functioning health and wellbeing 1 internationally childhood obesity rates continue to rise in some countries although there is emerging evidence of a slowing of this increase or a plateauing in some age groups in most european countries the united states and australia 23 however socioeconomic inequalities in relation to obesity and risk factors for obesity are widening 1 4 5 6 7 obesity is causally linked to chronic diseases such as diabetes coronary heart disease stroke hypertension osteoarthritis and certain forms of cancer 8 it is predicted that as the uk population grows and ages the burden of diseases associated with obesity will cost the national health service trust £10 billion per year by 2050 4 and will result in escalating numbers of early deaths as well as longterm incapacity and associated reductions in quality of life 8 childhood obesity is a particular concern and it is widely accepted that there is a link between childhood obesity and morbidity and mortality in later life 910 tackling obesity is therefore rightly highlighted as one of the major contemporary public health policy challenges and vital in terms of addressing health inequalities 48 the foresight review of obesity also highlighted the importance of taking a wholesystems approach to tackling the obesity epidemic 4 whereby interventions target the broader societal determinants of obesity 5 inequalities in obesity in the united kingdom like other highincome countries obesity is associated with social and economic deprivation with a higher prevalence in the lowest income quintile 11 current research suggests that this gradient is embedded with little evidence of change over time 10 geographical inequalities are also evident with hot spots in the northeast yorkshire and humber as well as in the east and west midlands 10 the social patterning of obesity in adults is mirrored in children also with children of low socioeconomic status having higher rates of obesity 711 data derived from longitudinal analyses suggest that social disadvantage accumulated throughout the life course has an impact on widening inequalities in relation to obesity in adulthood and that this trend is particularly marked amongst women 11 policy context addressing inequalities in obesity has a very high profile on the public health agenda in the united kingdom and internationally however there is a lack of accessible policyready evidence on what works in terms of interventions to reduce inequalities in relation to obesity existing systematic reviews have examined only the effects of interventions which reduce overall levels of obesity as opposed to the effects on inequalities in relation to obesity there is therefore no information to help policymakers and commissioners of services assess the types of interventions that are most effective at reducing inequalities in relation to obesity this evidence gap has been noted in the recent report of the priority public health conditions group of the department of healthcommissioned strategic review of health inequalities in england post 2010 1213 in which an overt call was made for evidence syntheses on the types of interventions that work to reduce inequalities in obesity prevalence how they work and under which circumstances they work the evidence for policy and practice information and coordinating centre report on childhood obesity also called for future systematic reviews to examine the effectiveness of interventions in reducing inequalities and improving the obesity levels of disadvantaged groups 14 similarly at the international level robertson et al identified the need for evidence of the reach and penetration of interventions in lower income groups as a priority area for research 6 the review also has international relevance given the importance attached to the development and testing of social determinants of health indicators and intervention impact evaluation by the world health organisation commission on the social determinants of health 15 it is critical for policymaking in this area that evidence of the effectiveness of different types of interventions at tackling inequalities is systematically identified appraised and synthesised furthermore there is increasing recognition amongst policymakers that to tackle complex health problems such as obesity effectively and to reduce health inequalities require integrated policy action across different intervention levels as well as across the life course 411 the organisation and implementation of such interventions are also important 16 against this backdrop the systematic review proposed herein will address this deficit in the knowledge base by reviewing primary studies of the effectiveness of interventions to reduce inequalities in relation to obesity in a wholesystems way the review will therefore examine public health interventions at the individual community and societal levels 17 it will also examine the organisation implementation and delivery of interventions intervention framework we have developed a framework for how inequalities in relation to obesity might be tackled this framework shows that interventions are characterised by their level of action and their approach to tackling inequalities following whitehead 18 there are four levels of interventions that can be used to tackle inequalities strengthening individuals strengthening communities improving living and school environments and promoting healthy macroscopic policies according to graham and kelly these interventions are underpinned by one of three different approaches to health inequality disadvantage gap or gradient 19 interventions are thus either targeted or universal in the proposed systematic review the obesity interventions will be grouped according to this framework for example as figure 1 shows exercise and diet advice is a targeted intervention aimed at strengthening individuals or communities in disadvantaged circumstances and underpinned by a disadvantage approach to health inequality within the framework a number of different types of interventional components exist although specific interventional components will tend to cluster within certain categories in the framework for example societal level interventions tend to involve regulationand taxationtype components some types will exist within more than one framework category and a framework category may contain more than one type of interventional component an intervention can also contain a number of different elements for example a schoolbased obesity prevention programme may involve educational regulatory and subsidy components methods and design the review will be carried out following established criteria for the good conduct and reporting of systematic reviews 2021 a study steering group comprising key stakeholders from the uk policy and research communities international representatives a statistician and a health economist will guide the research the review is registered with the prospero international prospective register of systematic reviews objectives this project has two objectives to systematically review the effectiveness of public health interventions in reducing socioeconomic inequalities in obesity amongst children and to establish how such public health interventions are organised implemented and delivered interventions the review will examine public health interventions at the individual community and societal levels which might reduce inequalities in relation to obesity amongst children ages 0 to 18 years in any setting and in any country the review will utilise the intervention framework and group interventions by intervention component typology where possible the obesity interventions will be grouped according to these types with the acknowledgement that some interventions might be crosscutting the review will consider public health strategies which might reduce existing inequalities in the prevalence of obesity as well as those interventions that might prevent the development of inequalities in relation to obesity however clinical interventions such as those involving drugs or surgery and laboratorybased studies will be excluded study designs a rigorous and inclusive international literature search will be conducted for all randomised and nonrandomised controlled trials prospective and retrospective cohort studies and prospective repeat crosssectional studies of the effectiveness of public health interventions at reducing inequalities in relation to childhood obesity studies with a duration of at least 12 weeks will be included a criterion used in previous cochrane reviews of interventions aimed at preventing obesity in children 22 and of the effectiveness of exercise for weight loss in adults with overweight or obesity 23 search strategy the search strategy will include the following electronic database searches medline embase cinahl psycinfo social science citation index assia ibss sociological abstracts and the nhs economic evaluation database the skills of a trained information scientist will be used to develop and implement the electronic searches all databases will be searched from start date to the present we will not exclude papers on the basis of language country of origin or publication date we will supplement the electronic database searches with website and grey literature searches we will handsearch the bibliographies of all included studies and request relevant information on unpublished and inprogress research from key experts in the field in addition we will handsearch the last two years of the five most common journals revealed by the electronic searches as well as journals identified by experts in the subject area we will also contact study authors for unpublished data on health inequalities outcomes in terms of outcomes we will only include studies if they include a primary outcome that is a proxy for body fatness data on related secondary outcomes will also be extracted from those studies which have a primary outcome we will include both measured and selfreported outcomes studies will be included only if the researchers examined differential effects with regard to socioeconomic status or the intervention was targeted specifically at disadvantaged groups or individuals living in deprived areas data on the organisation implementation and delivery of interventions will be extracted using existing methodological tools which assess the implementation of complex public health interventions 16 adapted and refined for the purposes of this review examples of the implementation components that will be examined include theoretical underpinning implementation context experience level of the intervention team consultation andor collaboration processes and resources data extraction and quality appraisal the initial screening of titles and abstracts will be conducted by one reviewer with a random 10 of the sample checked by a second reviewer fullpaper study inclusion and data extraction will be conducted by two reviewers independently using established data extraction forms 20 24 25 26 27 28 29 any discrepancies will be resolved through discussion between the authors and if consensus is not reached with the project lead the methodological quality of the included studies will also be appraised independently by two reviewers using the cochrane public health review groups recommended effective public health practice project quality assessment tool for quantitative studies 30 which includes amongst other things an examination of sampling strategy response and followup rates intervention integrity statistical analyses and assessment of adjustment for confounders we will use the quality appraisal criteria for descriptive purposes and to highlight variations between studies analysis and synthesis where possible metaanalysis will be used to synthesise data using comprehensive metaanalysis software based on the mean differences derived from the primary outcomes a fixedeffect model will be used for the metaanalysis unless there is evidence of heterogeneity between studies in which case a randomeffect model will be considered the presence of heterogeneity will be investigated with the use of a likelihood ratio test statistic whilst funnel plots will be considered to explore publication bias where metaanalysis is not possible however narrative synthesis will be conducted we will report our analyses in accordance with the prisma guidelines 31 the main analysis will examine the effects of individual community and societal level public health interventions on socioeconomic inequalities in relation to obesity using the multidimensional framework outlined in figure 1 and the typology of intervention components given in table 1 we will examine differential effectiveness by socioeconomic status interventions will also be grouped according to the age group targeted prenatal early years and primary and secondary schoolage interventions where data permit we will conduct demographic subgroup analysis by age gender and ethnicity discussion the review will consider public health strategies which reduce existing inequalities in the prevalence of obesity as well as those interventions that might prevent the development of inequalities in obesity the review will also serve as a mapping exercise of the types of interventions that have been evaluated in relation to tackling inequalities in relation to obesity amongst children thereby highlighting any gaps in the evidence base the review will also seek to establish how public health interventions which might reduce or prevent inequalities in obesity are organised implemented and delivered context is increasingly recognised as an important factor in the success of public health interventions 17 however the assessment of implementation has not really featured strongly in previous obesity reviews we will therefore develop refine and apply existing methodological tools which assess the implementation of complex public health interventions 16 the study design inclusion criteria in the review are broad given that whilst trials of individual and even community level interventions are likely we expect a dearth of experimental studies in relation to societal level interventions indeed large evaluations such as those of change4life and ensemble prévenons lobésité des enfants have all used a repeat crosssectional design this is perhaps because as law and colleagues observed 11 societal level interventions tend not to be easily evaluated using experimental study designs furthermore other recent systematic reviews of the effects of societal level public health interventions on socioeconomic inequalities in relation to health have located few relevant experimental studies 32 we anticipate that our extensive search strategy combined with the inclusive study design criteria will ensure that a sizeable literature will be located for synthesis recent cochrane heart group reviews of interventions that prevent and treat obesity amongst children found 22 and 64 randomised controlled trials respectively 2233 whilst we acknowledge that the literature on the effects of interventions on health inequalities is likely to be smaller we will maximise the likelihood of locating relevant studies by taking a more inclusive approach to study design contact study authors for unpublished data on health inequalities and evaluate interventions targeted at deprived groups or areas as well as studies that include comparative data on the effects of interventions on differential impacts across two or more socioeconomic groups the size of the available evidence base will also be extended because we will look at different levels of intervention individual community and societal we will also examine the full papers of all studies which fit our population intervention design and health outcome inclusion criteria even if there is no mention of socioeconomic inequalities in the abstract by adopting this strategy we will be less likely to exclude studies which undertook subgroup analyses by socioeconomic status but did not publish the findings in the abstract we will then contact the study authors for possible subgroup analyses and request any additional unpublished data on health inequalities this will increase the comprehensiveness of the search strategy and therefore the quality of the final synthesis once the evidence has been synthesised an implications for policy and practice review dissemination workshop will be held with invited nhs commissioners whose responsibilities include obesity department of health policymakers with responsibilities for obesity and inequalities user group representatives as well as uk research network representatives to discuss the results aid in the writeup and facilitate the translation of the findings into practice the technical report and executive summary will then be finalised and a short key findings summary of the research will be sent to relevant stakeholders the research will be disseminated via national and international academic andor practitioner crossover conferences and a policyorientated summary paper will be published on an open access basis so that it is freely available to practitioners and the public additional material additional file 1 medline search strategy 1946 to 10 october 2011 the search terms used in the medline electronic bibliographic database authors contributions clb is the principal investigator of this project and led the writing of the manuscript fch is the project manager and coinvestigator of the project and contributed to the writing and revision of the manuscript hjm and cds are coinvestigators of this project and contributed to the writing and revision of the manuscript all authors read and approved the final manuscript competing interests the authors declare that they have no competing interests

background there is growing evidence of the impact of overweight and obesity on shortand longterm functioning health and wellbeing internationally childhood obesity rates continue to rise in some countries for example mexico india china and canada although there is emerging evidence of a slowing of this increase or a plateauing in some age groups in most european countries the united states and australia however socioeconomic inequalities in relation to obesity and risk factors for obesity are widening addressing inequalities in obesity therefore has a very high profile on the public health and health services agendas however there is a lack of accessible policyready evidence on what works in terms of interventions to reduce inequalities in obesity methods and design this article describes the protocol for a national health service trust nhs national institute for health researchfunded systematic review of public health interventions at the individual community and societal levels which might reduce socioeconomic inequalities in relation to obesity amongst children ages 0 to 18 years the studies will be selected only if 1 they included a primary outcome that is a proxy for body fatness and 2 examined differential effects with regard to socioeconomic status education income occupation social class deprivation and poverty or the intervention was targeted specifically at disadvantaged groups for example children of the unemployed lone parents low income and so on or at people who live in deprived areas a rigorous and inclusive international literature search will be conducted for randomised and nonrandomised controlled trials prospective and retrospective cohort studies with andor without control groups and prospective repeat crosssectional studies with andor without control groups the following electronic databases will be searched medline embase cinahl psycinfo social science citation index assia ibss sociological abstracts and the nhs economic evaluation database database searches will be supplemented with website and grey literature searches no studies will be excluded on the basis of language country of origin or publication date study inclusion data extraction and quality appraisal will be conducted by two reviewers metaanalysis and narrative synthesis will be conducted the main analysis will examine the effects of 1 individual 2 community and 3 societal level public health interventions on socioeconomic inequalities in childhood obesity interventions will be characterised by their level of action and their approach to tackling inequalities contextual information on how such public health interventions are organised implemented and delivered will also be examined discussion in this review we consider public health strategies which reduce and prevent inequalities in the prevalence of childhood obesity highlight any gaps in the evidence base and seek to establish how such public health interventions are organised implemented and delivered prospero registration number crd42011001740

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introduction social networks are defined as the web of social relationships that surround an individual 1 the most commonly examined aspect of social networks with regard to breast cancer survival has been social network size previous studies have found that larger networks are associated with better survival after breast cancer diagnosis 2 3 4 5 6 7 in a nurses health study of 2835 women with any stage breast cancer kroenke and colleagues found that socially isolated women were twice as likely to die of their breast cancer than socially integrated women 4 in particular greater numbers of living children friends and close relatives were each related to lower mortality previous studies of social networks and breast cancer survival have often used the berkmansyme social network index which assesses numbers of friends and close relatives in addition to marital status community participation and religious participation and heavily weights friends and close relatives in the computation of the index 8 however this research has omitted study of the benefits that accrue to women who describe relationships as close as well as the costs of social relationships on breast cancer prognosis though large social networks may increase the odds that women will have friends and family to rely on for instrumental and socialemotional support they can also increase the likelihood of caregiving obligations to network members since women comprise up to threequarters of informal caregivers 1112 while potentially rewarding or beneficial 13 caregiving can be physically and emotionally demanding and has been linked to lowered immune function 14 poorer mental health 15 lower cognitive function 16 higher coronary heart disease risk 1718 and higher mortality 19 caregiving responsibilities can lead to strained relationships between network members large family networks may produce substantial demands although larger social networks can increase levels of socialemotional support the emotionally sustaining quality of a relationship social networks can also produce relational strain or conflicts between members increasing stress and causing biological effects 20 that jeopardize survival 21 22 23 no one has examined whether social burden modifies the influence of social networks on breast cancer outcomes therefore we evaluated associations between social network members ie the presence of a spouse or intimate partner number of first degree relatives club participation and religious participation with mortality outcomes considering the modifying influence of both social support and social burden we examined several social network members with outcomes consistent with previous analyses though the womens health initiative cohort lacked specific information on numbers of friends we focused particularly on relative networks based on the strength of previous findings of relatives with breast cancer mortality 4 because people often turn to family in need 2425 and because people rely more on relatives than friends for instrumental types of support 26 we hypothesized that larger social networks particularly relative networks would be related to lower mortality in women with breast cancer in those with higher perceived social support and that women with high levels of social burden would experience less benefit from network members we considered associations in 4530 postmenopausal women from the whi with invasive breast cancer methods study population the design of the whi has been previously described 2728 in brief the whi observational study is a multiethnic cohort of 93676 postmenopausal women ages 5079 enrolled 19931998 at 40 geographically diverse clinical centers throughout the united states eligibility criteria included ages 5079 postmenopausal status willingness to provide informed consent and at least a threeyear life expectancy the whi clinical trials study includes 68132 women with the same basic eligibility who agreed to participate in controlled clinical trials of diet or hormone therapy recruitment methods are detailed elsewhere 29 at baseline participants provided detailed information about demographics psychosocial factors medical history and known or suspected risk factors for cancer through a selfadministered questionnaire medical history was updated annually in the os and every six months in the ct by mail andor telephone questionnaires human subjects review committees at each participating institution approved the protocol we included participants with data at baseline on social networks social support and social burden from both the os and ct without a history of breast cancer at baseline those missing social data had less education lower social support higher social strain lower physical activity and higher bmi and were less likely to have had a mammogram in the prior two years prior to study end in 2009 4530 were diagnosed with invasive breast cancer study participants contributed 31184 personyears followup followup ranged from 0 to 144 years with a median followup of 69 years of these women 354 died during followup with 190 from breast cancer data collection breast cancer ascertainmentbreast cancer cases were initially identified from annual selfreport of medical history and then confirmed by medical record and pathology report review by physician adjudicators at local clinics all cases were centrally adjudicated and characteristics coded using the surveillance epidemiology and end results coding system 30 invasive breast cancers confirmed by central review were included as cases final adjudication and coding of histology hormone receptor status and her2 status was based on pathology report review and performed at the whi clinical coordinating center using the seer coding system 31 mortalityattribution of cause of death was based on medical record review by physician adjudicators at the local clinical centers who were blinded to information about social networks with central final adjudication 30 the national death index was crosschecked with participants at 23year intervals social networkssocial network members included a spouseintimate partner club ties religious ties and firstdegree relatives women were asked are you currently married or in an intimate relationship with at least one person women were also asked how often have you gone to meetings of clubs lodges or parent groups in the last month and how often have you gone to a religious service or to church during the past month for these questions response options included not at all in the past month once in the past month 23 times in the past month once a week 26 times a week and every day in addition women were asked whether or not they had sons daughters sisters and brothers and if yes how many women were asked further whether their mother and father were still alive women reported 023 firstdegree relatives with an average of 3 male and 3 female relatives we categorized this variable to enable comparison to previous analyses of relatives as part of the bsni 8 though social network members were similar to those included in the bsni questions about relative networks did not ask about degree of closeness and information on friends was not collected therefore we analyzed each network member separately and did not evaluate a composite measure social supportsocial support was assessed using nine items chosen from the medical outcomes study questionnaire 32 participants ranked on a 5point scale how often specific types of support including emotional support affection tangible support and positive interaction were available the summary score ranged from 9 to 45 with a higher score indicating more social support internal consistency for the score was high no clinically meaningful categories exist for the mos social support scale 33 so we categorized social support into quartiles based on the distribution of women in this study social burdensocial burden included both caregiving responsibilities and social strain as in previous whi analysis 34 caregiving responsibilities were assessed by are you now helping at least one sick limited or frail family member or friend on a regular basis social strain was evaluated with four items derived from a measure of the negative aspects of social relationships 35 women were asked of the people who are important to you how many get on your nerves 2 ask too much of you do not include you try to get you to do things you do not want to do responses ranged from none to all items were summed to yield a social strain score that ranged from 4 to 20 with higher scores indicating greater social strain internal consistency for the score was high social strain was also categorized into quartiles covariatescollection of data for breast cancerrelated variables was previously described information on other covariates was selfreported at the time of the social assessment initial analyses were adjusted for age study arm and time between social assessment and breast cancer diagnosis aside from age we included in minimallyadjusted models those factors inherent to the study that may influence associations but were not population characteristics analyses were adjusted additionally for family history of breast cancer mammogram within the past two years disease severity sociodemographic characteristics reproductive variables behavioral and related factors body mass index smoking physical activity and comorbidity we considered other covariates as presented in table 1 but only included those in analysis that were significantly associated with the outcome in minimallyadjusted analyses or that influenced the magnitude of the association of interest by at least 10 covariates included those considered a priori to be important potential confounders of the association between social networks and breast cancer mortality statistical analyses using analysis of covariance we regressed potential confounding variables against categories of relative network size adjusted for continuous age analyses of social network members and mortality outcomeswe employed cox proportional hazards models for failuretime data to assess associations of categories of social network members assessed at study onset with time to event our primary aim was to evaluate associations stratified by levels of social support and burden however we analyzed and reported main effects in the text to facilitate comparison to previous papers therefore we evaluated associations of social network members with time to breast cancerspecific mortality and allcause mortality 3637 personyears of followup were counted from the date of diagnosis until the date of death or end of followup whichever came first we conducted tests for linear trend computing wald statistics for all analyses minimallyadjusted results were compared with those adjusting for multiple covariates as described above we also conducted sensitivity analyses eliminating those who died within the first year of analysis stratified analyseswe evaluated effect modification by social support and strain stratifying women by high and low levels of social support or strain using both a median split to maximize power and a split between the third and fourth quartiles to capture associations among those with very high levels of support or strain compared to those with lower levels to assess the potential influence of social networks on mortality in the context of caregiving we stratified by caregiving status when associations differed across strata we used wald tests to evaluate interaction terms of dichotomous stratification variables and either continuous or dichotomous variables as indicated results for minimallyadjusted models were similar to those adjusted for multiple covariates as presented in tables 2 3 4 therefore because of the complexity of the data we have presented multivariateadjusted associations only all statistical tests were twosided the criterion for statistical significance was p 005 results women with larger relative networks had a greater likelihood of a live birth an earlier age at first birth and a larger number of children they were more likely to be married provide caregiving and indicate religious participation but less likely to participate in clubs those with larger relative networks were less likely to have a college education and had lower income whites were less likely than nonwhites to have large relative networks relative network size was related to behaviors consistent with a pattern of responsible caregiving including lower alcohol intake and a greater likelihood of never smoking but was otherwise related to a lower level of daily selfcare exhibited by lower levels of physical activity and higher bmi however larger relative network size was related to a higher likelihood of having a mammogram within the past two years disease characteristics were largely unrelated to relative networks though women with fewer relatives had more hormone receptor positive tumors main effects analyses social support social burden and allcause mortalityin analyses adjusted for age study arm and time between psychosocial assessment and diagnosis social support social strain and caregiving were each marginally associated with allcause mortality results were qualitatively similar in multivariateadjusted analyses though associations were nonsignificant these variables were not associated with breast cancerspecific mortality social networks and mortalityin main effects analyses of social network members being married was weakly related to lower allcause mortality in minimallyadjusted models but adjustment for income attenuated the association neither religious nor club participation was related to outcomes in minimallyor in multivariateadjusted analyses in minimallyadjusted analyses relative network size was inversely related to allcause and breast cancerspecific mortality though adjustment for covariates particularly sociodemographic factors attenuated associations in sensitivity analysis results were qualitatively similar stratified analyses social networks and mortality stratified by levels of social supportsocial support did not modify associations between relative club and religious network members and mortality but it did modify the association between having a spousepartner and mortality specifically split along median levels of support being married was related to lower allcause mortality among women reporting higher but not lower than median levels of social support in contrast being married was related to higher breast cancer mortality among women reporting lower but not higher than median levels of social support there were no apparent differences by levels of social support split at the third and fourth quartiles social networks and mortality stratified by levels of social burdencaregiving responsibilities strongly modified the relationship between relative network size though not other network members and risk of mortality the positive relationship between number of relatives and mortality appeared exclusively among caregivers the pattern of association particularly for breast cancerspecific mortality was positive and monotonic with higher categories of relatives positive relationships between relative network size and allcause and breast cancer mortality outcomes were somewhat stronger among those with higher levels of social strain when analyzed by median levels of social strain but this pattern was more evident in the highest quartile of social strain there were no other significant differences by social strain for mortality outcomes regardless of approach to stratification in sensitivity analyses omitting those who died in the first year after baseline results in stratified analyses were qualitatively similar discussion consistent with expectation associations of social network members and mortality depended on levels of social support and burden being married predicted lower allcause mortality among women reporting high not low social support by contrast greater relative network size was related to higher allcause and breast cancerspecific mortality among those with high levels of social burdenthose providing care to friends or relatives or those experiencing high levels of social strain adjustment for sociodemographic and other covariates did not attenuate these findings these findings suggest the need to assess the context of support and burden in womens social relationships to understand their influence on breast cancer survival in general researchers have found that larger network size predicts lower postdiagnosis mortality 2 3 4 5 6 kroenke reported striking findings showing that larger numbers of living children close relatives and friends were each related to lower breast cancerspecific mortality 4 these findings described associations between close relatives and outcomes although the whi and nhs did ask similar questions about numbers of children findings suggest that results depend on how social networks are measured and that feelings of closeness capture benefits inherent in relationships but that alternate approaches are needed to explore costs no previous work addresses this specifically though previous findings point to the possibility that network members can create burdens for women postdiagnosis 5 although a larger number of friends and relatives was related to earlier diagnosis and better survival in white women in the blackwhite cancer survival study 5 women reporting less frequent contact with friends and relatives were conversely more likely to present with early stage disease and had a commensurate lower risk of mortality or 05 supportive social network members can confer benefit consistent with our findings regarding a supportive spouse however women with larger relative networks may also have greater obligations and stresses that impinge directly on health or preclude prioritizing daily selfcare in the whi a larger number of relatives was related for example to lower physical activity and higher bmi two risk factors for poor breast cancer prognosis 3839 frequent contact with friends and relatives in the context of strained relationships or caregiving may have adverse consequences for health with important implications for longevity strained relationships may lead to earlier mortality 2223 that a larger number of relatives was associated with higher mortality among those providing caregiving suggests that negative relationship dynamics within families may have adverse consequences for health further research is needed to understand the mechanisms of social networks on breast cancer survival thus the nature and quality of womens relationships matter to health no one has previously examined this within the context of breast cancer these findings are novel these findings suggest a great need for understanding how social burden influences the impact of social relationships on womens health future research should consider this question in larger groups of women of different ethnicities and socioeconomic status a study strength was the ability to adjust for variables related to breast cancer mortality including stage tumor size nodal status grade hormone receptor status and her2 status a second strength was its size with over 4500 women another strength was the ability to adjust carefully for lifestyle demographic and socioeconomic variables one important limitation was the lack of data on friendship networks we were unable to draw conclusions regarding their influence these findings likely underestimate the benefits of social networks on breast cancer survival though missing data may also lead to an underestimate of the costs since women missing any social data reported higher social strain and lower social support despite a large sample size we had limited power to assess associations of modest size related to this was the inability to fully examine associations for each type of relative nevertheless a post hoc analysis revealed that the positive association of relative network size and mortality was driven primarily by a positive association between numbers of siblings and mortality particularly among women with high social burden future research should consider the impact of specific types of relationships another limitation was the inability to adjust for breast cancer treatment however disease severity influences treatment course and adjustment for treatment has not substantially influenced associations over and above careful adjustment for disease severity in other studies 440 we cannot rule out that this may affect findings women with few relatives were more likely to have erpositive cancer which has better prognosis than ernegative cancer however adjustment for breast cancer treatment as a confounding variable may be inappropriate since treatment is unlikely to influence social network size it may be more useful to determine how network members influence treatment decisions a final limitation was that social measures were not updated in these analyses nor was there assessment of social history before study enrollment numbers of relatives were assessed at baseline only and followup measures of social support and burden were inconsistent across the os and ct cohorts though social network size appears consistent over time 4 levels of support and strain may change over time the assessment of social networks at one time may capture the cumulative biological impact of social relationships over time inaccurately however the evaluation of the impact of social networks on mortality after breast cancer reflecting potential costs not just benefits is unique in the breast cancer literature to summarize the presence of a supportive spouse predicted lower mortality but larger relative networks predicted adverse outcomes among those with high levels of social burden given the rising costs of health care and the aging of the population there is a growing need to understand how social relationships influence disease progression

though larger social networks are associated with reduced breast cancer mortality there is a need to clarify how both social support and social burden influence this association we included 4530 women from the womens health initiative who were diagnosed with breast cancer between 1993 and 2009 and provided data on social networks spouse or intimate partner religious ties club ties and number of firstdegree relatives before diagnosis of those 354 died during followup with 190 from breast cancer we used cox proportional hazards regression to evaluate associations of social network members with risk of postdiagnosis mortality further evaluating associations by social support and social burden caregiving social strain in multivariateadjusted analyses

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interfaces no 2 year 13 062023 lc6 eissn 18477755 doi 1015291sic213lc 6 2 according to sarah mcfarland in ecocollapse fiction a relatively new trend in ecocriticism in literature postapocalyptic scenarios are treated as realistic speculations of human extinction where positive outcomes such as the possibility of human survival and social rebirth indicating a happy ending are no longer offered ballards urban violence novels are likely to fit into this category as his protagonists fail to follow the pattern established in traditional postapocalyptic fiction where in mcfarlands words a heroic leader of a group of good survivors overcomes the catastrophe whereby a somewhat brighter future for the human race is suggested the plot of these novels deploys and intertwines the motive of ecocollapse in the futuristic enclaves in which the residents need to uncover what it would mean to be human in an anthropogenic climatechanged world … when there is no redemptive ending here denatured ecosystems in mcfarlands words are reflected in urban zerowaste gated communities engrossed in novel therapies violence crime and murders thus presenting the world that cannot sustain the human futures symbolized by new births as such they deal with ecoprecarity and marginalization of human psyche and morality which eventually reflects on vastly diminished ecosystems leaving terminal effects according to thomas knowles ballards urban violence novels depict the consequences of human and media manipulation of urban spaces which leads to a dystopian future where the boundaries between natural and artificial are blurred this can be seen as a reflection of the potential collapse of the natural world due to human actions which is the primary concern of the ecocritical perspective as we examine ballards terminal new edens we will see a paradoxical idea emerge in order to destroy the world we must first summon it into being the act of summoning the world into existence suggests that the dystopian and destructive societies depicted in these novels are not mere cautionary tales but rather a reflection of a society that has already been summoned into being in this case it represents the creation of a world that prioritizes technological advancement and materialism over nature and human connection the paradox lies in the fact that in creating a world that has the potential for destruction we may ultimately be responsible for its demise if humans continue to ignore the detrimental impact of their actions on the environment it could ultimately result in the collapse of ecosystems as interfaces no 2 year 13 062023 lc6 ballards urban violence quadrilogy 2 portrays humans living in a denatured environment that conditions their behavior generating people whose counternatural actions and illicit deeds make them become waste themselves since the analysis of the urban landscape in cocaine nights and supercannes highlights how the physical and psychological environment of the gated communities impacts the characters wellbeing they seem likely to be examined through the lens of the fourth wave of ecocriticism that focuses on public and environmental health as it acknowledges the importance of investigating how the environment impacts human health the gated communities are a manifestation of social and psychological entropy because they isolate the residents from the natural environment and promote a technologically dominant order that causes harm to both individuals and the community as a whole the examination of the impact of the urban landscape on human health is crucial in understanding the complex relationship between humans and their environment and how this relationship can lead to both positive and negative outcomes the apocalyptic images of the city in ballards catastrophe novels signal the divorce between humans and city between human being as biological entity and civilization and point to a complete transfiguration of civilization into a jungle ballards urban disaster novels on the other hand emphasize a somewhat different form of separation that is now occurring between humans and nature his residents identify themselves with denatured environments embodied in artificial sports stadiums high rise blocks and closed communities the physical entropy dominant in his clifi novels and evident in a disfiguration of the natural landscapes by natural disasters is replaced by the social entropy caused by denatured and chaotic manmade urban landscapes in ballards urban disaster novels the physical entities that make up the urban landscape such as cars motorways skyscrapers business parks and resorts represent the social and psychological detachment of human beings indicating an environment that is severely compromised ballards urban violence quadrilogy delves deeper into these ideas and the notion of psychological entropy and mental disorder that arise from the humancentric approach to the natural environment it reveals the presence of the concept of transcorporeal space in a more nuanced form of environmental illness that affects the zerowaste gated communities it offers a glimpse of a possible future for humanity where people cluster together in gated communities that are likely to interfaces no 2 year 13 062023 lc6 emerge in urban areas due to the blurring lines between beneficial and harmful technologies the ultramodern enclaves embody the ultimate manmade creations born out of humans alignment with the city and their separation from nature the residents of these communities are in constant consumption and are consumed by their environment which is exhibited in their continuous physical and mental interaction with their urban surroundings the notion that the external paradise fails to provide an internal one is reflected in the absence of proper moral emotional and spiritual guidance among the residents leading to an internal hell the utopia created by the transformation of the natural environment is artificial and lacks authenticity the alienation of people from nature results in their destruction of it and the emergence of environmental illness ultimately this leads to the destruction of the children of their own creation the cities as the eruption of urban violence becomes detrimental to their mental health cocaine nights and supercannes differ from dump wastes and locations affected by natural disasters in that they take place in closed zerowaste communities that appear perfect but ultimately foster social and psychological entropy social entropy which represents the decline of civilization encompasses various negative behaviors such as alienation anomie and deviance and has a disordering effect on a particular social structure entropys implications are pessimistic suggesting that humans are adapting to future isolation due to the inevitable progress of technology and that they are readily embracing nonsense and collective madness which are obstacles to achieving any form of coherent structure csíkszentmihályis concept of psychic entropy is relevant to the selected novels as it refers to a state of inner disorder that impairs the selfs effectiveness and weakens its ability to sustain attention over time this notion of disorder is evident in the characters of the novels who struggle with integrating and organizing their inner selves due to the disorganizing effect of their environment essentially the zerowaste communities in the selected ballards urban violence novels provide an apt environment for inducing and sustaining such behaviors the principally negative technological effect reflects human alienation loss of purpose in life the disintegration of the human mind and above all the disorder in communal life these settings breed and embrace madness and transgression as a welcome change to the exhausted human spirit that needs revolutionary and fresh ideas to spur it the extravagant estrella de mar resort is described as the emotionless realm where the entropic current soothed the surfaces of a thousand swimming pools in this place even though the seas only two hundred yards away it is noteworthy that none of the villas looks out onto the beach the villas are encircled by unused empty pools as spending time there may require socializing with people the man not only caused certain changes in his natural environment that have led to environmental illness but he himself through his lifestyle and trends that support different forms of alienation from nature in all aspects of life and refusing to acknowledge the strength of the bond between his body and his surroundings the human and morethanhuman world has also changed to match the altered surroundings environmental health affects public health and any harm caused to the environment automatically triggers damage to peoples health therefore in the context of ballards urban violence tetralogy alaimos statement that living places should never be regarded as merely background but as active participants in the lives of individuals is a viable standpoint interfaces the retirement oasis estrella de mar on spains costa del sol is a community in which environmental imbalance is primarily triggered by the technological treatment of urban settings it is a residential haven in which society has succumbed to a technologically dominant order that causes societal harm that cannot be mitigated this phenomenon emphasizes the inextricable link between environmental health and human health and explains how the transfiguration of space affects humans with british and french expatriates organizing lavish parties that promise the revival of the place and streets and buzzing nightlife full of illicit activities the existence of nature is evoked in amateur porn films entitled the wildlife of residencia costasol this is a sarcastic recollection of the nature association and the novel teaches us that there are not many accounts of natural space as it was transformed with the futuristic cities interfaces no 2 year 13 062023 lc6 eissn 18477755 doi 1015291sic213lc6 7 on the surface estrella de mar represents a retirement paradise in which architecture is dedicated to the abolition of time as befitted the ageing population of the retirement havens and even wider world waiting to be old such a community or a private kingdom of the future was intentionally and carefully designed to produce a sense of timelessness the first insight into it provides the architecture of the place and the vast majority of its population is early retired citizenry which indicates an even greater desire to escape the thralldom of work and sink into boredom and passivity after years of capitalist labor ballards increasing focus on suburbia develops discontinuity of natural and social topography leading to the loss of the inherent intrinsic values of right and wrong the pervasive expansion of urban space has left natural marks behind leaving only remnants to stand out as a peculiar landmark of aestheticization among the palms and eucalyptus trees sheltering the comfortable villas what dominates the vista is the linerlike prow of the club nautico topped by its white satellite dish the prevalence of concrete and metalized features generates discontinuity between the inherent interdependence of humans and nature instilling bland emotions and a kind of social fatigue this is mainly due to the very advanced futuristic community and the established order the leisure society in which among other things boredom and drug abuse produce rather indifferent residents and where all this ceaseless activity these art festivals and town councils are a form of social parkinsonism the urban climate inflicts more anthropocene conduct suppressing natural entities that were highly important in the recent past thus the nexus of the anthropocene era are human needs and desires humans have gained the ardent and selfish ambition to internalize the natural space adjusting and configuring natural landscapes to fit their requirements breaking the natural cycle of mutual serving and cohabiting in estrella de mar crystal clear swimming pools flawless tennis courts luxurious villas and the whole community morph into a living organism to use alaimos metaphor paradoxically the living organism here resembles a living death as trance induced by antidepressants and cctv are among the things that reanimate the community and are groomed to flourish the flourishing occurs through murders rapes drugs and setting fellow citizens yachts on fire for pure pleasure the community enjoys simultaneously being a victim and transgressor paralyzed to experience life without the thrill of vice interfaces no 2 year 13 062023 lc6 eissn 18477755 doi 1015291sic213lc6 8 the omnipotent effect of narcoma syndrome the desire for early retirement and incessant boredom have made the residents become unconcerned with common trivial matters that once had the power to stimulate them so they resort to something abnormal and bizarre to draw their attention and to incite social interaction even only for the sake of staging some violent and criminal acts the transformation of the cities triggered the obsolescence bringing about the reconfiguration of urban space accompanied by gentrification which highlights the utter change in the demography of a modern metropolis the novel introduces us to the general concept of denatured futuristic gated communities the elysium which is supposed to provide perpetual coziness and carelessness its a fortified mediaeval city this is goldfingers defensible space raised to an almost planetary intensity security guards telesurveillance no entrance except through the main gates the whole complex closed to outsiders its a grim thought but youre looking at the future this pertains to the immaculate condominiums that shall be allencompassing drug dealing theft pornography and incessant leisure time marking a new kind of renaissance and are flawless only on the surface the costasol complex is not the only residential and gated enclave in the world this pattern of the dream world is spreading further having replicas much greater in size this is a carefully planned future and a development plan for the people who want to retire too soon paying extra money to have all those facilities but the whole complex seems abandoned as its residents are watching tv with the sound turned down while being isolated in their capsules the phenomenon of social fatigue is taking its place more frequently within these denatured futuristic enclaves as people are trying to cocoon themselves into their perfect worlds desiring to maintain their state of not being bothered either by social interaction or the current affairs of the outer world in this way they prolong the effect of inertia and lethargy of everyday life eventually leading to brain death the fact that the natural space is gradually diminishing within these futuristic gated communities is because all that space is totally internalised humans gained more authority to take control over nature since they only needed a small particle of that external space which would eventually be the sky over those fortified complexes through their satellite dishes the need for a interfaces no 2 year 13 062023 lc6 eissn 18477755 doi 1015291sic213lc6 9 natural environment is completely irrelevant here the whole complex satisfies all their needs thus leading to isolation and brain paralysis the spatial transformation inflicts radical and innovative changes in the patterns of thinking and grasping socializing and living in general in particular when it comes to the illusionary paradise of estrella de mar the perfection of this realm and the enviable energy of its inhabitants is based on the pathological and sociopath motives and behavior this is induced by the denatured landscape that dominates the coming of the new millennium producing artificial and blasé emotions and citizenry with malevolent intentions indulged in social pathology after years of living under a capitalist regime and incessant labor human beings are getting more and more detached from nature they seek utopianlike destinations dream of early retirement and refuse to deal with the problems of socialization capitalism has actually incited a new revolutionary order in the global economy and lifestyle where technology has replaced humans in various positions and people pursue different pastimes as their primary occupation this economic system has also established destructive views on nature and perceives it separately leading to the transformation of human relations ultimately it has led to the age of surveillance capitalism a digital future that could have disastrous consequences for humanity and freedom yet the morphogenesis of dystopian architecture within these urban spaces demands inhuman transformations resulting in social and psychic entropy characterized by different forms of transgression ie alienation deviance in regular patterns of human behavior etc all leading to disorder in a given social structure human behavior and mental state have always been conditioned and incited by states and circumstances in their individual or wider environment hence the urban unconventional surroundings instigate unnatural human responses and entirely deviant behaviors something that distances man from nature and his primordial role this occurrence is supported by the fact that the complex constituted a private kingdom with its own currencies of mind and meaning for instance in these private kingdoms prostitution is seen as a means of giving new meaning to the passive lives of women the rape scene on the parking lot or recording an amateur porn film is regarded as a private thing or done for private matters this further marks the boundaries of mans willingness to interfere with the outer world in addition religion fails to interfaces no 2 year 13 062023 lc6 eissn 18477755 doi 1015291sic213lc6 10 provoke collective awakening from narcoma syndrome and surges of severe violence in these denatured enclaves as indicated in the novel religion should appear later when the human race begins to near its end the residents have no hope for the rebirth of the society the only thing they have been left with is acceptance of the approaching ending yet the ending does not seem promising it would be the termination of the amnesia in which they have insulated themselves remaining unconcerned and detached while waiting for another dose of some drug or sedative ballard further strived to investigate that inner space the landscape that reflects the incessant alienation portrayed by the western culture of the twentieth century continually altering the technologies of communication production and consumption naturally as gasiorek argues the extensions of capitalism have filled all the trivia of everyday life yet more attention is turned to excessively rapid changes in a globalized economy that advanced telecommunication systems enabled one of the consequences of such changes is that an individual becomes adjunct to the system in which he is imbricated leading to the displacement of the human organism this is evident in the decline or complete loss of community and social values destabilization of the human spirit and psyche deterioration of family life and crime rates rapidly rising in supercannes we gain insight into the slightly altered urban surroundings as compared to estrella de mar the metamorphosis of landscape and psyche have changed to such an extent that they match each other the novel is set in a zerowaste landscape which embodies an illusory realm of perfection and an ultramodern workers paradise it is a hightech business park with the technocrats at top offices as the key psychological zone it is also a huge experiment in how to hothouse the future in this business hub corporate managers enhance their productivity with fun yet they cannot fully relax outside their workplaces since capitalism left indelible marks for years to come in edenolympia greater divisions within the human race are visible which can be supported by the pervasive and expansive desire in this urban space to purify the place of all imperfections and human waste the violence and subordination of certain races brought to existence the environmental justice movements that emerged from certain racial inequities and the belief that the interfaces no 2 year 13 062023 lc6 connection between people and their environment may challenge environmental health concerns the business operations at this location rely on the exploitation of immigrants in the nearby town of cannes la bocca to avoid potential depression the executives resort to abusing the immigrants as a form of stress relief as one character explains whenever he felt the blues coming on he would take one of the security men into la bocca and provoke an incident with a passing immigrant it worked a treat this abusive behavior towards immigrants also serves as an executive therapy with the character noting close colleagues too cheered up i asked if i could keep a professional eye on the exercise soon we had an active therapy group with a dozen senior executives trashing arab cars beating russian pimps violent attacks and rapes of immigrant women turned into a kind of weekend fascism as they provided certain health benefits for the executives drained by the work within this denatured enclave nature is relegated to a secondary role valued primarily for its capacity to create a sense of purity and order however ecocollapse manifests itself in various forms including the camouflaging of the landscape artificial lakes expansive car parks and aquaparks take precedence over natural features this corporate haven is designed to transform provence into europes silicon valley dominated by glass and metal office blocks separated by artificial lakes and forested traffic islands that offer only a token nod to natures existence these gated resorts are founded on the premise of providing refuge from the outside world yet they hide their true nature behind various facades for example psychotherapy is used to justify the molestation of immigrants while glimpses of nature are aesthetically disguised with artificial substitutes the residents obsession with perfection and their desire to conceal the rawness of nature results in the transformation of the earthscape expensive materials such as milled ivory are used to create more refined surfaces intended to soothe the stressed wheels of the stretch limousines canary palms serve their purpose in these office blocks merely as a palisade and guard along the verges and cannas only as a gaudy representation and reception to the business park most of the business park is manmade in order to cleanse the place of all waste human and natural this is indicative of the fact that humans are striving to gain even greater power over nature they aspire interfaces no 2 year 13 062023 lc6 eissn 18477755 doi 1015291sic213lc6 12 to leave none of the leverage to nature and they aim to force the ecosphere to adjust to their lifestyle and not vice versa the rest of the edenolympia displayed oldmoney discretion being only the mirage of the biosphere even the residents romantic relationships appear to be against nature and natural processes im a devoted husband that must strike you as totally deviant no just a little against nature the response suggests that the idea of being a devoted husband is not entirely in line with the natural order of things implying that there may be something artificial or contrived about the romantic relationships in the community such attitude toward marriage and relationships in general indicates that the dwellers of the business park ingrained a strain of deviousness the bizarre mood that revolves around the need to play on masochistic terrain it points to the artificiality of the society created in edenolympia where even the natural order of romantic relationships has been distorted by technology and the pursuit of wealth and leisure moreover it implies that in this millennium one does not long for the enemy but to become the victim denoting a shift in human mental state or disorder that is adopted as one of the weird surges of culture this may indicate that nature be it in physical or abstract form is losing its supremacy and precedence however nothing is as it first seems here as over the swimming pools and manicured lawns seemed to hover a dream of violence the residents claim that there is almost no crime here as abusive activities and violence along with other perverted ventures serve as psychotherapy since their desire for innovative approaches to entertainment is insatiable the residents are in danger of losing their sense of limits and exhausting all the options and possibilities the residents gradually become acclimated to the corporate environment and this is reflected in their personal relationships which have transformed into as gasiorek argues contractual liaisons between objects given the above it is plausible that urban areas are prone to violence and can alter nature leading to human brutality and atrocities mans alienation from nature merged with technological advances and spatial transformations has given man immense power and control over nature however in the process humans have forgotten how to coexist and rely on nature as they did in the past to edenolympia like estrella de mar is shrouded in a haze of violence and voyeurism due to the corporate order that governs it clinics prescribe powerful tranquilizers for those who refuse to deal with mental crises or stressful situations inducing the narcoma syndrome that deters residents from movement and leads them into idleness and emotional numbness to dispel the illusion of love residents cherish their marriages by watching their partners infidelities and getting excited just by looking at it or by watching kiddie porn or even having intercourse with thirteenyearolds shockingly these activities are not even regarded as serious crimes in this sense the novel suggests that the human realm of intimacy and relationships has undergone the same transformation as natural and urban landscapes similar to cocaine nights the residents of edenolympia are consumed by work and lack moral and spiritual values unable to conceive of a life beyond their workplace in this consumerist society consumer capitalism is the real crime erasing morality and even commodifying the human soul the existence of bizarre and perverse consumer trends also gives rise to unsettling entertainment conclusively as mcfarland attests various nuances of ecocollapse here threaten the dominion of the human subject creating a postapocalyptic scenario that may lead to human extinction rather than a rebirth of the same society within the framework of an ecocollapsed future that presents denatured ecosystems as evident in estrella de mar and edenolympia human subjects whose bodies are embedded in the larger environment must reconsider their identities and recognize that everything outside is already within as alaimo advocates this implies that humans are inseparable from nature and that any opposing approach can only lead to ecocollapse the anthropocene era offers a plethora of devastated personal landscapes damaged by the belief in human exceptionalism ecocollapse destabilizes the world and renders it uninhabitable to humans challenging the potency of human superiority and exceptionalism in cocaine nights and supercannes the city symbolically represents a place where one is likely to succumb to dehumanizing forces that exist in urban settings the characters easily adopt an urban consciousness and behave accordingly the sterility of urban life is reflected in the interfaces no 2 year 13 062023 lc6 ultramodern zerowaste buildings whose residents are unable to live creatively as part of the flow of time and nature due to their alienation from nature and their daily subjection to the mechanics of civilization the scarcity of natural spaces creates a ballardian landscape of sociopathic violence transgression and pornography networks reflecting the social entropy that characterizes modernday society and the damage done to human relationships in these futuristic gated communities whose residents are obsessed with security they defend and protect their territory from any potential threats from the outside world as a result the ecosystem is dying there exists a stark contrast between the closedoff enclaves and the external world which is open to all these enclaves are like fortresses providing their residents with all their daily needs and rendering them secure enough to exclude themselves from the outside world while this may reduce everyday stress prevalent in modern metropolises such as commuting or traveling to procure necessary items it fosters social exclusion and has a negative impact on social capital moreover it often instills a false sense of security amplifying paranoia and increasing isolation in contrast the external world does not offer the same level of security and amenities but still maintains a certain level of socialization though gentrification is gradually leading to an increase in gated residential communities this is due to limiting its territory to the defensible internal space in which human life and body are a programmed code that cannot operate outside of structured activities and cannot act spontaneously as gasiorek argues the aftermath of the citys implosion into the natural environment shifts the focus from the correlation between humans and nature to the interface between humans and machines in which machines become anthropomorphized and humans mechanized this in turn shows how environmental problems breed various human problems resulting in hindsight of complete detachment stemming from the colonization of natural space alternatively this implies that places are never just background as alaimo contends as they are intimately connected to humans with their own beings and needs not existing solely as human resources living in hightech urban settings means mechanizing their residents and conditioning their mindset by nourishing their physical and mental health so that it matches their surroundings humans are treated and perceived in a mechanized manner which casts the body as passive interfaces no 2 year 13 062023 lc6 plastic matter humans are determined to obsessively repulse nature completely oblivious to the fact that the environment is not located somewhere out there but is always the very substance of ourselves as alaimo suggests ballards terminal edens are only a simulacrum of perfection and nonpresence of nature as it would not be viable to protect nature by merely creating separate distinct areas in which it is preserved and protected from the rest of the world under the pressures of mechanization man fails to properly understand the bond between humans and the morethanhuman world and acknowledge the fact that the environment is in alaimos words a human landscape in which people blend into their living spaces in addition these circumstances contribute to creating an atmosphere of environmental illness where an individuals humanity as they are part of nature is constantly threatened to be violated in other words ones health the physical emotional and spiritual wellbeing along with environmental health are very likely to become ultimately damaged the violence within urban settings that results from environmental illness symbolically embodied in ones spiritual emotional and mental paralysis appears to be just as devastating as the effects of natural disasters on both rural and urban settings the social psychological and psychic entropy within urban settings is as dreadful as the physical entropy that strikes the planet in the form of a natural catastrophe in such a world humans cannot retrieve or reclaim their natural aspects as they are violated and diminished by the advanced mechanization of daily life deviant behavior and bizarre pursuits in these anthropocene enclaves cannot renew and revive the life and atmosphere of the communities rather they can only incite the threat of extinction as an end point as mcfarland suggests the constant opposition between the city and nature in ballards fiction is not a simplistic matter of good and evil or positive and negative nor is the opposition of urbanrural codes expressed solely through the emphasis on the opposition between the masculine and feminine with the masculine representing the city and civilization and the feminine representing the natural world by stressing the adverse effects of natural disasters on both natural and urban habitats in his clifi novels as well as the civilizing process of natural landscapes by human activities in his urban disaster and urban violence novels ballard seems to suggest that human beings need to adopt a holistic vision interfaces no 2 year 13 062023 lc6 eissn 18477755 doi 1015291sic213lc6 16 of humans within the environment this vision relies on our perception of human bodies as transcorporeal spaces inseparable from the environment and the recognition that human health is undeniably affected by the health of the environment the quest for such a vision is likely to transform the opposed urbanrural codes into a new system of dynamic interrelatedness that requires more sensitive approaches to the symbiosis of the human and nonhuman world

the fiction of j g ballard closely examines contemporary environmental and climate change issues through the authors consistent juxtaposition of natural and urban settings which are often associated with individuals on both a personal and global level while his early works clifi novels primarily focus on globalscale physical catastrophes caused by human activities his later works urban disaster and urban violence novels portray the urban catastrophe that threatens to invade mans personal sphere this inquiry attempts to demonstrate that the inhabitants of the enclosed societies portrayed in ballards urban violence novels namely cocaine nights 1996 and supercannes 2000 are inexorably drifting toward a state of social and psychological entropy these communities strive to condition their cognitive framework to align with the sterile and impersonal urban environment thereby eliciting us to envisage incessant reciprocity with the milieu by introducing the concept of transcorporeality to connote the fundamental nature of the symbiotic relationship between humans and the morethanhuman world and the consequent blurring of boundaries between body and environment this paper aims to illuminate the critical significance of environmental health and the notion that the human body or psyche is inextricably intertwined with its surroundings

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introduction the global media landscape has undergone significant change during the last 20 years with the emergence of new media technologies for example between 2001 and 2015 global internet penetration increased from 79 to 464 the proportion of internet access at home increased from 18 in 2005 to 46 in 2015 additionally the itu claims that there were 7 billion global mobile cellular subscriptions at the end of 2015 this corresponds to a penetration rate of 97 an increase from 738 million in 2000 global 2g mobile cellular network coverage grew from 58 in 2001 to 95 in 2015 these dramatic changes in global communications are altering the way that cultural sojourners are negotiating their adaptive experiences and approaches investigating intercultural phenomena should reflect those changes current approaches to intercultural communication rely on traditional views of culture for example callahan and burnett identified four main categories of cultural identification within intercultural studies these include nationality ethnicity religion and language however scholars are arguing that these designations do not represent individual perspectives castells for example argued that individuals are using technology to escape the contexts of existence other disciplines such as anthropology have argued that culture is wholly perception and fractured identities have received increasing attention in multiple disciplines bauman introduced the idea of the rootless nomad for the modern individual navigating increasingly complex relationships and identities the traditional views of culture are being increasingly challenged another argument for investigating perception within media and global culture is the importance of media during cross cultural migration in the past 20 years scholars have identified an increasing role of media in the sojourner experience valenzuela and mccombs for example have argued that an individuals need to orient him or herself in a new cognitive environment correlates with his or her use of media they contend that the higher the need for orientation the more the sojourner tends to rely on the media the goal of this research study is to identify the perceptions that individuals have of their media use as they navigate a new culture for the purpose of this research this includes individuals who have a primary socialization in one culture who then move to and navigate through a foreign or host culture this study will attempt to avoid traditional substantialism by employing qmethodology a less familiar research approach in intercultural communication this method allows for the identification of perceptual categories of media upon cultural migration free from traditional categories of culture review of the literature validation for this research is drawn from four areas of literature that are closely associated to media and perception migrant perspectives increased global media use increased global movement and the perceptual approach to doing culturalcontextual research together these contexts provide the background and justification for an investigation of this type one of the reasons there has been a lack of research into categories of media perceptions within the adaptation process is that researchers tend to favor an approach that by its very nature is behaviorally based this is because much of the intercultural research focuses on intercultural competence or the role of the sojourner in adapting to the new social milieu there are obvious hegemonic implications resulting from the combination of behavioral conformity and communication competency a problem recognized earlier by habermas in the area of adaptation the kinematic or behavioral approach looks at the uses or behaviors surrounding a specified elementthe outward cultural behaviorsas opposed to the cultural values themselves that cause the behavior the dynamic approach on the other hand investigates the cultural reasons or perspectives inherent within behavioral decisions some intercultural researchers including croucher have taken this approach because the dynamic approach privileges mindsets and perception qmethodology is used here to identify cultural subjectivity while research detailing the perceptual categories within culture is limited research looking at the intersection between media use and culture is not furthermore while there is research investigating how cultures perceive communication for the most part it falls short in creating categories of perceptions two notable exceptions here are toennies work on gemeinschaft and gesellschaft cultures and ongs writings on oral and print cultures there are hundreds of studies that detail how one culture uses media within a second social context this includes how culture influences the use of media technologies cultural perceptions of technology and the sociocultural fit of technology however most of these studies focus on media selection within the migrant milieu rather than how sojourners perceive their media choices this area of research includes correlating demographic variables with adaptation the globalizing effect of media and the impact of media use on adaptation while valuable none of these studies addresses the subjective perception of cultural media because media use has increased worldwide this changing context is a major influence within global psychological structures arnett claimed that the largest psychological consequence of this change is that it results in transformations of identity or how people think about themselves in relation to the social environment increased global participation is more than simple media consumption increasingly global media participants are engaging in message or content creation concurrent with increased global media use is an increase in international migration according to the international organization for migration this movement has increased from 150 million migrants in 2000 to 230 million in 2013 the united states alone had an estimated 46 million migrants in 2015 in 2014 13 million foreignborn people immigrated to the united states an 11 increase from 2013 middle eastern countries tend to have the highest percentage of immigrants by percentage of population the united states is the top receiving country with 45 million immigrants accounting for 20 of the worlds migrant population this increase in global movement combined with increased global media use creates a new type of context for intercultural communication researchers last with increased movement and media exposure global information does or at least can transcend geography because virtual communities are now competing with traditional geographic communities communication research needs multiple ways to approach intercultural phenomena as hall noted cultures arise wherever there is human interaction and virtual communities are becoming an increasingly popular venue for interaction facetoface interaction while still dominant and vital no longer holds a monopoly on the marketplace of communication individuals are creating meanings free from the constraints of geography based on the previous research including the lack of cultural perceptual research the changing nature of international identity increased global movement and the differences among traditional definitions of culture the following research questions guide the current study rq1 what are sojourner perceptions of media while navigating new cultural contexts rq2 do sojourner perceptions of media in the new cultural milieu differ method introduced by william stephenson in 1953 q methodology provides a foundation for the systematic study of subjectivity q methodology is a behavioral research approach that utilizes factor analysis to measure and reveal the subjectivity of any situation the process involves the use a research tool called a q sort which requires an individual to rankorder a group of statements that represent a particular domain of subjectivity called a concourse the concourse is made up of actual statements that individuals have made at one time or another while expressing their opinions about a specific topic the q sorts are then factoranalyzed and groups of individuals who have sorted the statements in nearly the same way are clustered together into factors each factor represents a specific group of people who have common attitudes and are likeminded thinkers about the research topic after the factors are formed the researcher interprets the factors and the beliefs of the individuals in each of the factors are explained in detail as part of the q methodology process a personal interview is conducted with each subject after completing the q sort and the information from these interviews is used to add breadth and depth to the explanation of the factors for this study the concourse was a group of statements centered on the idea of how do i use media to adapt these statements were gathered from a diverse group of sources that included research findings from crosscultural media studies intercultural blogs and international migrant focus groups the focus groups helped to validate clarify and edit the statements so that they would represent the migrant experience and be understandable to international sojourners all statements were in english a sample of 48 statements was selected from the population of opinions that best represented how individuals use media within their new cultural experiences it is this sample of 48 statements that the subjects used to create a q sort of their own attitudes about media and adaptation the subjects for this project consisted of 47 young adults q methodology uses a small number of subjects because in q technique subjects are treated as variables rather than a sample of the population brown explains that when selecting respondents all that is required is enough subjects to establish the existence of a factor for the purposes of comparing one factor with another he goes on to say it is rarely necessary in work of this kind to obtain large numbers of each type five or six persons loaded significantly on a factor are normally sufficient to produce highly reliable factor scores and it is in terms of the relationships among the factor scores that general statements about an attitude are made increasing the number of persons on a factor merely fills up factor space but has very little impact on the scores to ensure the results of this study were representative of the typical cultural sojourner care was taken during the sampling procedure to have both genders represented and subjects who were in the typical target market age range for cultural movement because the purpose of the study was to determine perceptions of media use within the new cultural milieu subjects were only selected for participation if they 1 used media while navigating to a new culture and 2 if they moved into a new culture within the last 5 years the focus on media was a general one by far most of the participants in this study referred to online or digital media if they did use traditional media it was without exception accessed through digital devices we recognize that this may not be typical of all cultural sojourners however with 46 of the world currently connected to the internet and an estimated 53 by 2020 the future of migrant connectivity will continue to grow this is especially true when individuals move to locations with higher internet penetrations the next step was to have the subjects conduct their q sorts by reading through each of the 48 statements and ranking them on an 11point scale ranging from most like my feelings to least like my feelings after the q sorts were completed the researchers conducted individual interviews with each of the participants to probe further into the subjects decision making process to allow the subjects to express their thoughts and feelings about why they ranked some statements high and other statements low and to let them express their thoughts and feelings about media and their host culture the interviews used a structured questionnaire with the following questions why did you select two statements as being most like your experience why did you select two statements as being least like your experience the average time for each person to complete each q sort and interview was approximately 45 minutes in the analysis researchers used principle components analysis to generate an unrotated factor matrix which was then subjected to a varimax rotation to qualify as a reportable factor the criterion was at least two significant participant factor loadings at the 001 significance level once the factors were determined the investigators compared the significant positive and negative zscores for the statements that accompanied each factor those with a zscore greater than 10 were considered to be significant and they represent the most like and least like statements for each factor once the factors were determined investigators compared the significant positive and negative zscores for the statements that accompanied each factor statements for each factor with a zscore greater than 10 were considered to be significantly most like my experience and least like my experience finally the composite factor arrays for each factor wee derived from the rank scores assigned to each statement by the participants significantly associated with each factor factor scores that differed by 3 for each statement on each factor were considered to be significantly different labels and interpretations determined by the investigators for the following factors were predicated on the zscores calculated and the factor q sort values provided by the participants in the study they were also supplemented by the responses recorded from the interviews conducted with the participants results the factor analysis for this study yielded three significant factors that represented participant perceptions of media while navigating the host culture these three factors characterize general categories of perception and not necessarily the demographic identifiers of these individuals the unique value of qmethodology as it is used in this study is that it sidesteps the traditional obstacle of operationalizing culture in order to probe how individuals think about their experiences this expands the discussion of results past general demographic representations and moves the conversation into how individuals think additionally qmethodology is not concerned with how many participants fell into a particular factor loading or what the participant demographics are for the factors the focus is to identify perspectives across these traditional boundaries this study found three significant factor loadings of media while in the new culture these three factors answer rq1 what are sojourner perceptions of media while navigating new cultural contexts factor 1 the first factor was defined by 22 perceptual statements that were common among responses in the sample researchers labeled this perceptual factor instrumental adaptors the factor loadings for this group indicate that these subjects perceived media as useful for negotiating their new cultural context instrumental adaptors view media as an essential tool to expedite fitting in as one respondent from mexico stated surrounding yourself with the media from the new country the quicker you learn the language and it helps to adapt to most instrumental adaptors using and understanding the host media is essential to successful functioning within the new culture this is shown by this groups high agreement with the statement i have had to use media here in the new country to be successful in school or business which was significantly different than the other two factors additionally these individual tend to use more media including host media than they did back home secondly these instrumental adaptors view media as an important component of their experience respondents scored relatively high in the area of using media as an instrument for enhanced functioning while media are important new country media use for instrumental adaptors scored exceptionally high while both new media use and the desire to adapt are important to instrumental adaptors the media found within the new context was far more important than any other social variable measured perhaps this characteristic is a result of this groups strong desire to fit in to the new cultural milieu instrumental adaptors view media as speeding up cultural functioning instrumental adaptors are very positive about living in their new social context and doing it through the media is seen as the best way of functioning many sojourners feel that the media was central to their new cultural context including pop culture programming one respondent from china stated i learned about us from news oprah and tv shows this does not indicate however that instrumental adaptors completely reject all media from their home culture while they do acknowledge that they use little home culture media they still indicate using it somewhat although minimally connected to home media they are still connected to the home culture 1675 5 6 i dont want to adapt to this new countryill just keep in touch with friends and family through personal media 2148 5 factor 2 the second factor was defined by 17 statements that were common among individuals in the sample researchers labeled this factor social connectors because of how they use the media to connect socially to both their home and new social contexts social connectors view media as an essential tool to maintain and build social networks as one respondent from russia stated i would be homesick which is what i use the media forto stay connected for social connectors relationships are central within their new cultural functioning both relationships in the home culture and those in the new fitting in to the new culture is important for social connectors but not as important as maintaining relationships from their previous social context one respondent noted i felt better about coming here because although i wouldnt be able to return to canada i could still stay connected to friends this characteristic is demonstrated by social connectors acknowledgment of continued home media use as well as their identification of home media as being an aid for navigating the new culture for social connectors home media play an important part in their psychological health they do not feel isolated within their new social context because of the availability of home media social connectors use media and especially home media for emotional support one respondent from ecuador noted i am a social person the fact that im away from home doesnt mean that i want to be antisocial i decided to be me so its not going to prevent me from having new friends now cultures and new perspectives perhaps the most important finding for the social connectors is that the newculture media played a very small part in their new cultural experience this group for example had a small interest in using hostculture media but yet had a high motivation to adapt to the new context the implication here is that host media at least for this group have a very small role in navigating their new cultural context factor 3 labeled abiders by the researchers the factor 3 group was defined by 18 statements that describe people who tend to use media in the new culture in same way they used media in their home culture abiders while familiar with host culture media are not highly motivated to either significantly increase their usage or to use the media to navigate the new host culture the lack of media use may be due in part to their overall lack of desire to adapt to the new host culture the dominant characteristic of the abider is the disbelief that media plays a significant role in functioning within the new culture this disbelief is manifested in two ways first abiders believe that all media both home and host are the same they do not differentiate between home and host media even while they are navigating a new host culture one respondent from mexico stated there are the same types of media here and back home i havent been surprised at all because there is no difference in the mediait is the same second they feel that media are not able to keep them connected in any significant way while they may still use the media there is a distinctive lack of faith in what the media can actually do for them another respondent from mexico observed im here for a year and no matter what it will be hard for me to stay connected for these individuals media has little or no effect on new cultural perspectives it is not surprising then that abiders demonstrated the highest tendency to use the same types of media that they used before host insertion their consistency of media use can be explained by their desire to retain their previous cultural perspective the abider sojourner strives to keep his or her previous identity another respondent from brazil summed up this finding succinctly i dont want to lose my identity it should be noted however that while these individuals do not want to lose their identity they do not view media capable of causing that loss one unique and significant statement for the abider was media consumption has caused me to unlearn my home culture the negative zscore indicates a significant disagreement with this statement media has little power for the abider for abiders fitting in to the new culture does not appear to be a goal and they do not seem perturbed by this perspective they have a slightly higher propensity to use home media than the instrumental adaptors although it is not as high as the social connectors perhaps most importantly the abiders see little power in the media and they do not see the media as an important part of the new cultural milieu rq2 the second research question asked about differences between sojourner perceptions to answer this question the statements were separated into six media perception categories the significant zscores for these statements within all three factors were then tabulated to provide cumulative zscores for each of categories figure 1 provides a visual map of factored participant perceptions along each of these six categories revealing the variety of media views among the three factor groups figure 1 factor group zscores for six media perception categories the main findings regarding rq2 fall into two categories first participants perceived that media serve as an instrument while navigating a new culture second motivation to fit in is an important consideration for how media is viewed as one might expect instrumental adaptors tend to place a high importance on media while adapting of the three groups these individuals are the most likely to perceive media for a specific purposein this case fitting in perhaps their dependency on newculture media is a natural extension of their overall feelings of media importance while this research does not provide justification to argue that media use equates with using media to adapt it does raise questions about overall media consumption and cultural nagivation the lowest cumulative instrumental score was noted by the abiders individuals with this mindset demonstrate little or no propensity to use media in the new cultural context this in itself is an interesting finding as it indicates that there is a type of sojourner who does not view media as a useful tool to aid cultural insertion in terms of media perception there was also a stark difference between the instrumental adaptors and the social connectors that difference centered on the types of media used to facilitate cultural movement it should be noted that both of these groups reported higher levels of motivation to fit in their divergence occurred in how they saw medias role in this process the instrumental adaptors favored new culture media while the social connectors preferred home media this finding both validates and amends valenzuela and mccombs argument that individuals use media to orient their adaptation it validates in that there is a type of cultural sojourner that relies heavily on host media to navigate the host culture exactly as described it amends the argument in that the media that sojourners rely upon is not necessarily host media individuals can and do rely on home media to orient themselves within the host culture motivation to fit in to the new culture also plays an important role in how sojourners perceive media the findings for rq2 demonstrate two perspectives related to motivation as previously mentioned instrumental adaptors and social connectors scored highest on the desire to adapt this coincides with other research findings on motivation and adaptation however what is most enlightening is that abiders reported little to no motivation to adapt at all this is a finding that has not received much research attention the implication is that there is a type of sojourner with little or no motivation to fit in to the new culture yet seems to be perfectly functional within the host culture these individuals may avoid pressures to adopt new cultural values and perspectives discussion the results of this study point to two main implications perceptions vary within as well as across traditional cultural categories and the perceptual approach allows for theories to be tested and amended in new ways perceptual categories a main implication of this study was the finding that perceptions of media varied across geopolitical borders this is consistent with much of the research on cultural uses of new media scholars such as lévy have posited that online communities are creating their own cyberscapes transcending traditional geographic ethic linguistic or religious singlepoint definitions of culture this argument extends to the elimination of spatial identifications for culture that cultures are not geographicallybased anymore this research found multiple instances of individuals from the same country falling into differing factor sets for example there were four respondents who selfidentified their home culture as japan within this group of japanese respondents two factored out as instrumental adaptors while two others were social connectors while this finding is limited and extremely premature it at least suggests a question within many intercultural studies does country of origin for example indicate a cultural perspective again the findings only indicate that individuals from the same geographic region fell into different perceptual groups more work needs to be done with different methodologies to understand this finding better however this implication allows researchers to sidestep traditional means of operationalizing culture and in so doing create perceptual categorizations of culture that can then be tested this research has demonstrated that local origin or language descriptions do not necessarily identify how individuals perceive their lifeworlds additionally and probably most telling is that individuals who may have been acculturated within the same geographic region and within the same linguistic system do not necessarily share the same values or behavioral perceptions while more study needs to be done it is possible that sojourners from the same countries can have dramatically different perspectives of media in the migrant process the above discussion presents an interesting type of research approach one that expands not only how we operationalize culture but also the types of research questions that can now be asked like kramers concept of endless integration and hofstede and bonds argument for synergy this approach frees intercultural scholars to move beyond substance designations and into perceptual categories for decades intercultural scholars have struggled with differentiating between multicultural actions in order to identify cultural perspectives and behavioral triggers berry for example has argued that cultural sojourners can live within multiple cultures at the same time an idea that has been around since at least gordons work on the assimilation process between minority and dominant populations this research validates these perspectives instead of operationalizing an individuals culture based on where he or she lives an individual can be identified based on how he or she perceives his or her world different view of theories this research has shown that theoretical descriptions of the cross cultural communication process both fit and deviate from mainstream theoretical approaches this includes for example assumptions for cross cultural adaptation while this study does not address adaptation specifically the perspectives identified in this research have implications for adaptation research each of the three factors fit into theoretical models describing adaptation they also provide evidence for deviation as well thus while intercultural theories are accurate for some cultural perspectives they are inaccurate for others for example because of the abider perception of low adaptation motivation these individuals do not fit into the theoretical model of crosscultural adaptation while instrumental adaptors and social connectors who express high adaptation motivation do social communication has long been associated with successful crosscultural adaptation this study validates this argument those who have a high adaption motivation also tend to have higher social motivation as well reciprocally those who have the least motivation for adaptation also note the least interest in social communication of all the theoretical implications of this research perhaps the most intriguing is the way that the qmethod separates the theory of culture from the context of culture we have labeled this idea polytheoretical contextualization a perceptual analysis allows the researcher to test multiple theories or descriptions within the same cultural context additionally it permits the researcher to identify which theories explain which cultural behaviors above all the perceptual typology approach to culture allows researchers to pinpoint which theoretical approaches correspond with which perspective an example of the polytheoretical argument is that the findings within this study both validate and deviate from argument put forth by valenzuela and mccombs that the higher the need for cultural orientation the higher the tendency to rely on media instrumental adaptors expressed a high need for acculturation as well as high media use to attain adaptation these individuals validate the valenzuela and mccombs argument in that they selfreported higher reliance on media and the ability of that media to ease the migrant process on the other hand social connectors demonstrated a high desire for cultural functioning but a lower use of media to fulfill that desire individuals within this perspective typology do not look to media or at least look to it much less than other typologies as an instrument of adaptation so this research implies that there are multiple perspectives of media and adaptation that both support and conflict with the valenzuela and mccombs argument a second example of polytheoretical contextual application of this studys findings is again in kims crosscultural adaptation theory this theory addresses a sojourners desire to adapt assuming that most or all migrants want to adapt to the host culture crosscultural adaptation theory also argues that lower adaptation motivation correlates with decreased psychological health this study has identified a type of cultural sojourner that corresponds to crosscultural adaption theory but there is also a type of cultural sojourner who has little motivation to fit in stays connected with home through homeculture media and has a strong desire to retain their previous identity these participants noted satisfaction and happiness combined with lower adaptation motivation this finding is in stark contrast to the theoretical descriptions on crosscultural adaptation theory perhaps newer forms of social media are creating cyberscapes that are altering the way individuals adapt to the new milieu the overriding idea behind the polytheoretical approach demonstrates the necessity of understanding all types of cultural perspectives perhaps more importantly scholarship must be careful about amalgamating individuals into convenient groupings obviously geographical linguistic ethnic and religious groups tend to have a dominant mindset or perspective many would agree however that dominance fluctuates according to group this fluctuation necessitates attention by identifying all perspectives a better understanding of culture can be achieved while more research could be done in this area this initial finding can have an influence on the way media is approached in future research studies conclusion the combination of increasing global media use increased migration and reliance upon media for adaption can have a dramatic impact on the way scholars approach intercultural issues this research has attempted to understand these changes by analyzing perspectives embedded within this combined milieu these perspectives can now be used to understand types of intercontextual movement free from the traditional labels of geopolitical borders linguistic systems or racialethnic categories as with any exploratory study there are limitations within this research the current study is restricted to the 18 to 34 yearold demographic as individuals in this age group are typically heavy users of social media and have the potential to use media the most while adapting however most subjects tested were college students with an even higher degree of media use furthermore the sample was composed of mostly students at a large private university in the western united states where students have free wireless internet access while on campus in the dormitories this may differentiate them from other types of media users additionally the current study grouped all media together and with few statement exceptions asked respondents to do the same future research should break out this variable to test for differences between different types of media both traditional and new as well as variants of media consumption studies could also focus on demographics with varied levels of media use to see if they might differ from the current sample and should survey an individuals general media use and internet media use to determine where how often and for what purpose he or she uses the media the current study could be easily repeated to other demographics to unveil attitudes about media and adaptation and how they might compare to one another a last limitation of this study is the method itself although qmethodology has been around for some time it has not been used extensively in communication research and many scholars are unfamiliar with it because of this there is a tendency to evaluate it similarly to r methodology this is natural as a part of the method is factor analysis however sampling reliability and validity all work differently within q and it is more in line with qualitative research than quantitative this method is essentially a way of understanding how people think it is not appropriate for any type of cultural inference or predictions of any individual or group mumford recognized the dilemma of traditional cultural overrepresentativism of one group over another more than 40 years ago he argued that there is a neverending process of contextual perspective as no one cultural type is capable of encompassing all the latent potentialities of human beings therefore researchers must break the mold of traditional contextual definitions authors address

new media are changing the way identities are managed this is increasingly relevant to global communication lévy 2000 the purpose of this article is to understand how these changes effect individual perceptions of media within a new cultural environment by applying qmethodology to cultural migration this research asked cultural sojourners to rank subjective statements of media factor analysis were applied to the rankings which provided three main perspectives of media these three perspectives include instrumental adaptors social connectors and abiders these perspectives provide an alternative to traditional categories of culture and allow for a unique understanding of cultural adaptation theory

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a mathematical approach to the collective learning dynamics has been developed in 1 2 3 to model individual and collective learning by interactions involving individuals and groups of individuals the method combines the mathematical tools of the kinetic theory of active particles 4 and the theoretical tools of evolutionary game theory 56 in more detail the sequential steps of the approach are as follows 1 the level of learning of a certain knowledge is modeled at the microscopic level by a scalar variable u ∈ 0 1 where u 0 represents the lowest level of achieved knowledge and u 1 the highest admissible level 2 the whole system can be subdivided into functional subsystems in which each one of them plays a different role in the learning process 3 the overall state of the system is delivered ie a probability distribution function over the microscopic state defines the collective state of the system while macroscopic states are provided by weighted moments of this probability distribution 4 the dynamics develops through encounters which can be either individualbased or between individuals and the whole system 5 the output of the interactions is modeled by developments of the theoretical tools of the evolutionary game theory in which players are probability distributions or their averaged quantities 6 the probability distribution mentioned in item 3 is the dependent variable of a differential system its dynamics is obtained by a balance of living particles in the elementary volume of the microscopic states the interested reader is referred to 1 for additional information on the modeling approach to the survey 7 and to the book 4 for the related mathematical tools while additional details will be given in the next sections the contents of our paper rely on the observation that the perspective ideas proposed in 1 leave open various problems that are definitely worth of future investigations in more detail this present paper focuses on the study of the interactions between learning dynamics and other types of dynamics that can be accounted for by kinetic theory tools in fact some recent papers have put in evidence how models which involve interactions of different dynamics can generate even outputs that could not be foreseen but which are confirmed in reality a possible example is given in 8 where it is shown that an unfair wealth policy can lead to a radicalization of the opposition to the governments which has produced such policy the opposition also ends up involving the social classes that apparently take advantage of the policy however unfair it is further applications are suggested in 9 focusing on the interactions between learning and behavioral economy an additional example is the study of the complex interaction between learning in crowd dynamics in which the walking strategy is induced by learning socialemotional behaviors these examples discussed in the last section motivate the contents of this paper which is devoted to the modeling of the influence of learning dynamics on other types of dynamics this is the main novelty of our paper where in addition the use of discrete states of learning dynamics and of the variables of subsequent dynamics is developed also exploiting a new metrics to model the distance between the interacting entities the contents are proposed through three other sections section 2 provides a general description of the different theories of learning dynamics in the framework of cognitive sciences some specific issues are extracted without claim of completeness from a vast and heterogeneous literature that is still waiting for a unified interpretation this section attempts to open a dialogue between mathematics and cognitive sciences looking forward to a unified approach generated by the mathematical sciences section 3 defines the specific systems to be modeled and then shows how the approach proposed in 1 can be developed thanks to new conceptual approaches towards the modeling of the class of systems presented in section 2 the conceptual novelties consist of using the discrete probability distribution to describe the state of the system and the discrete stochastic games to model the interactions and in dealing with a hierarchy where learning precedes a consequent dynamics section 4 deals with applications selected among several possible ones to show how the approach can be specifically referred to modeling these applications specifically refer to the two aforementioned dynamics firstly the modeling of wealth policy opposition to governments up to radicalization and then the interaction between learning walking strategy in crowd dynamics lastly we consider a third application ie the immune competition in heterogenous multicellular systems where learning leads to proliferative and destructive events the presentation of these case studies concludes with a critical analysis that starting from the theoretical achievements of our paper looks ahead to research perspectives state of the art this section introduces topics related to collective learning that constitute the basis for the modeling approach developed in our paper the contents are presented in three subsections the phenomenological description of collective learning is treated in the first subsection an overview of the existing mathematical approaches known in the literature is delivered in the second subsection the third subsection provides a critical analysis that defines more precisely the objectives of the mathematical method proposed from section 3 phenomenological description of collective learning we start examining the interrelations between individual and social learning which appear as two different aspects of the same phenomenon of collective learning to clarify how they are interconnected the concept of individual learning has come to be embedded into social and cultural contexts and interactions due to the growing interest in vygotskys theory 10 to retrospective examinations of the role of social interactions in 11 and in the subsequent banduras revisiting 12 two strands are involved the cognitive acquisitionoriented conception of individual learning with respect to the situative participatory concept 13 learning occurs in individuals minds and as we elaborate later it takes place as a social and participatory process offering two distinctively different points of view on learning the idea of social learning originated with the development of psychology sciences 14 and occurs when the individual learns new behaviors and concepts from others because of its lack of rigor it has been ignored by psychologists over the years and it has been relegated at best to the study of the background context not exactly on a par with the learning of the individual 15 social learning is often combined with other dynamics for instance participation and proenvironmental behavior while in general small differences are referred to individual and social learning after this general presentation we now provide referring to 16 some characterizations of social learning that can be useful for the modeling process that we want to develop later the first aspect to keep into account is the active social mediation of individual learning a person or a team helps an individual to learn eg a teacher and a child forming a joint learning system another important characterization which deserves to be mentioned consists of considering the social entity as a learning system a good example is the case of a collective agency that as a collective acquires more knowledge understanding or skill eg a business organization develops internal procedures that satisfy the efficiency of customer requests finally the last aspect we wish to point out is learning to be a social learner an important dimension of learning to learn is how that participate in and capitalize on the social milieu over the years a frequent confusion has emerged between the concept of social learning itself and its potential outcomes the lack of clarity on this matter has reduced the possibility to distinguish precisely the two however different types of learning 17 for these reasons in 18 the authors try to answer the question what is social learning and they identify three key problems with the term as it is currently used in the literature • social learning can possibly occur even without any previously organized interaction while social networks can contribute to the interaction dynamics 19 20 21 • the quality namely level of depth of this type of learning can span from superficial levels to deep conceptual levels which can involve groups at different scales 2223 in conclusion social learning is effective if a change in understanding appears in the individuals involved in the dynamics closely connected with the previous analysis is the concept of collective learning which is a complex dynamics that has been variously defined in different ways it is mainly viewed as a dynamic and cumulative process an interesting example is provided by the deep learning algorithms recently tested in the diagnosis of skin cancers 24 the algorithm combines visual processing with deep learning a type of artificial intelligence modeled by models of neural networks learning is then an evolutionary process related to the dynamics of collective knowledge 25 among the characterizations of the collective learning we want to bring the analysis done in the context of transfer knowledge in technology milieu where in 26 the author approaches a definition of collective learning and its interpretation within spatial theories first collective learning to be interpreted as a social process of cumulative knowledge 2728 in conclusion if learning is to be considered collective learning then it must be cumulative and interactive learning is a dynamic process developed on the basis of an element of continuity over time on which knowledge rests and accumulates furthermore the new knowledge of a first inventor is transferred through other agents on the basis of an element of synergy and an interactive process giving rise to a cumulative process of knowledge creation a brief survey of mathematical approaches due to the lack of a sociopsychological theory on social learning mathematical approaches also differ significantly from one another waiting for a possible uniformity in this subsection we present some approaches bearing in mind the three sequential steps that occur in the rough simplification of learning dynamics in complex living systems toward modeling the first step of learning dynamics is the perception of inputs from other individuals these inputs are perceived within an individual domain within which the said inputs are effectively felt thus interactions take place and trigger a learning process that changes their level of knowledge from the point of view of theoretical modeling very interesting studies have been carried out in the framework of statistical physics methods in recent years a very broad review concerning this general framework was presented in 29 where the authors focus their attention on different aspects emerging in social dynamics all such aspects seem to be related to the fundamental issue of how the interactions between social agents allow the emergence of a macroscopic order starting from a disordered initial situation in 29 the authors focus on some conceptually homogeneous topics sharing the common aspect according to which individuals are viewed as adaptive rather than rational agents that communicate and interact with each other in the context of social dynamics the agreement is one of its most important aspects everyday life presents many situations in which it is necessary for a group to reach shared decisions one of the pioneer contributions to the modeling agreementdisagreement dynamics which might be referred to opinion dynamics has been proposed by a model proposed by weidlich 30 subsequently a modification of the ising model has been proposed to model specific features of opinion dynamics 3132 where the spinspin coupling is deemed to model pairwise interaction while a background field represented the cultural majority or propaganda subsequently a branch of opinion dynamic is based on the socalled voter model 33 which was first considered in 34 as a model for species competition kinetic models of continuous opinion formation involving both the exchange of opinions between individual agents and dissemination of information are proposed in 35 36 37 in the framework of stochastic models the axelrod model played a prominent role 38 by enlightening the two mechanisms which according to his theory are fundamental in understanding of the dynamics of cultural assimilation namely social influence and homophily collective learning on the other hand has a very strong influence also in the modeling of collective motion this latter appears in nature with common effects eg observation of flocks of birds and swarms of insects motivated several studies in the past 3940 humans display similar behavior in many instances such as pedestrian motion panic and vehicular traffic pedestrian behavior has been empirically studied since the 1950s 41 the first physical modeling was proposed in 42 by a comparison with navierstokes equations but already in 25 it has been observed that in the dynamics of living entities energy and momentum are not generally conserved in more recent years a new approach to behavioralsocial dynamics for pedestrian crowds in the framework of the kinetic theory of active particles has been developed by dealing with the modeling of crowd dynamics to show that collective behaviors are induced by individual bases interactions 4344 the learning dynamics have an important role in crowd models as the walking strategy takes advantage of what each individual learns from the other walkers 45 in this approach the level of stress is not simply modeled as a parameter but it is a variable whose dynamics is related to learning and social contagion critical analysis the mathematical modeling of collective learning should provide a characterization of all the fundamental aspects involved in the process and at the same time to be able to capture the fundamental aspects that determine the dynamical evolution of the system the main feature to tackle is the complexity of the living systems indeed the phenomenon we wish to describe can be represented considering a large collection of living entities which interact among them at microscopic level through nonlinear interactions the outcome of all the interactions determines the dynamical evolution of the overall system at a macroscopic level the aim of the present paper is to construct a mathematical framework suitable to capture the following aspects of the learning process • the individuals role in the collectivity collective learning modifies the individuals ability to develop interaction rules that evolve over time • learning dynamics living entities can learn not only by microscale interactions but also from the whole population the key problem consists of referring the dynamics at a microscale to treat at the macroscale • role of networks networks can have an important influence on the learning dynamics as observed in 9 both exogenous and endogenous networks have to be considered corresponding respectively to physically localized nodes and nodes generated by aggregations due to affinity principles mathematical tools the derivation of mathematical models to describe the dynamics of collective learning is developed in two consecutive phases firstly by defining a general structure capable of capturing the specific features of the class of systems under examination and subsequently by creating models related to well defined learning phenomena the derivation is obtained by refining the general structure by inserting into it models suitable to describe the interactions among the subjects involved in the learning dynamics examples of interactions between learning and social dynamics will be analyzed in the next section while only methodological aspects are treated here further conceptual developments are needed with respect to 1 because our paper addresses complex dynamics for which learning is an important component but only a preparatory step preceding other dynamics in fact in addition to the variables that characterize the learning process it is also necessary to include more variables characterizing the induced dynamics this brief introduction defines the content of this section that will be dealt with in the following subsections addressed to the main three themes 1 characterization of the soft variables and representation of the system 2 modeling of interactions 3 derivation of a general structure suitable to describe the collective dynamics of interactions between learning and social dynamics the study will be limited to the case where the microscopic variable is defined by two components ie learning and social the methodological approach can then be generalized technically in the case of a larger number of components as discussed in the last section of our paper hereafter we will use the following terminology active particles to identify interacting entities activity to indicate their status at the microscopic scale and functional subsystems with reference to the groups in which the population is divided soft variables and representation we consider a system of a large number of interacting entities with the following features • the system is composed by living entities which interact in a spatially homogeneous dynamics • the microscopic scale corresponds to the state of each entity modeled as an aparticle 4 • each aparticle interacts with the others at both the microscopic level and the collective set of all the particles therefore according to 4 we introduce the activity which is a vector variable with two components w u v where u is the component that characterizes the level of learning and v is the social component whose dynamics are also induced by u both u and v can be defined according to an occasionally used jargon soft variables in principles although accounting for sigmunds important book 46 soft variables are not measurable however we can conjecture and identify the minimum and maximum values that these variables may reach by defining a suitable interval where values are observed therefore normalizing with respect to that domain it is obtained u ∈ 0 1 ≡ d u and v ∈ 0 1 ≡ d v moreover local measures cannot be effectively made therefore it is convenient using discrete rather than continuous variables for instance a discrete equally spaced collocation can be used for the components u and v c u u 1 0 u n 1 and c v v 1 0 v n 1 therefore the representation is delivered by the discrete probability distributions f f ij f with n ∑ i1 n ∑ j1 f ij 1 if f ij is known porder moments are computed by weighted sums e p u 1 n n ∑ i1 n ∑ j1 u p i f ij and e p v 1 n n ∑ i1 n ∑ j1 v p j f ij if active particles are subdivided into m fss the following notation is used f r f r ij f r r 1 m our paper refers to systems where the total number of particles n is constant in time so that the normalization condition is written as follows m ∑ r1 n ∑ i1 n ∑ j1 f r ij 1 where each f r ij is a component of a probability as it has been divided by n modeling interactions the first step of the modeling of interactions consists of selecting those interactions that play a nontrivial role in the dynamics of the system while the second step consists of taking into account also a possible hierarchy among the activities u and v and eventually in modeling the output of interactions the stochastic game theory 4 describes their dynamics by means of the frequency of the interactions and the transition probability of microscopic states of the interacting active particles which pursue a specific payoff consistent with the strategy they are able to develop moreover rather than individual entities chasing their own payoff the whole population operates to achieve a collective wellbeing where the advantage is shared by everyone this concept is well expressed by the following quotation from ref 5 evolutionary game theory deals with an entire population of players all programmed to use the same strategy strategies with higher payoff will spread within the population the payoffs depend on the actions of the coplayers and hence on the frequencies of the strategies within the population since these frequencies change according to the payoffs this leads to a feedback loop the dynamics of this feedback loop is the object of evolutionary game theory this subsection shows how interactions can be described by suitable operators to be subsequently used in the derivation of the mathematical structure we are looking for according to the kinetic theory of active particles the dynamics of interactions involve candidate field and test active particles in detail we consider • test particles of the rfs with microscopic state u i v j and probability f r ij these particles are assumed to be representative of the whole system • field particles of the rfs with microscopic state u p v q and probability f r pq which are generic particles for each rfs • candidate particles of the kfs with microscopic state u h v k and probability f k hk which are generic particles for each kfs deemed to take due to interactions the state of the test particles the modeling of learning interactions can be achieved by the interaction rate which describes the number of encounters per unit time and the transition probability which denotes the probability that a candidate particle takes the state of the test particle due to interaction with field particles dealing with these modeling issues leads straightforwardly to derive the governing evolution equation which regulates the dynamics of the class of systems under consideration if we consider the simple case of one fs only a formal expression of the aforementioned terms is as follows η pq hk is the interaction rate of a hkparticle with a pqparticle namely between particles with states hk and pq µ hk is the interaction rate of a hkparticle with the mean state e of the whole system a pq hk models the transition of a candidate hkparticle into the state of the test ijparticle due to the interaction with a field pqparticle m hk models the transition of a candidate hkparticle into the state of the test ijparticle due to the interaction with the mean value within the system a balance of particles in the elementary volume of the microscopic state yields d dt f ij n ∑ hkp1 η pq hk a pq hk f hk f pq f ij n ∑ pq1 η pq ij f pq n ∑ hk1 µ hk m hk f hk e f ij µ ij e where all interaction terms might depend on f while the dependent variables are a function of time analogous calculations can be developed if the system is constituted by a number m of interacting functional subsystems d dt f r ij m ∑ s1 n ∑ hkpq1 η pq hk a pq hk f r hk f s pq f r ij m ∑ s1 n ∑ pq1 η pq ij f s pq m ∑ s1 n ∑ hk1 µ s ij m s hk f hk e s f r ij m ∑ s1 µ ij e s 7 still following the methodological style of presentation of our paper some indications can be given to show how a mathematical description of interactions leads to the derivation of the models mainly qualitative indications are provided leaving a detailed formalization to specific models let us indicate how a possible interaction hierarchy can account for the sequential combination of the two different dynamics namely learning which corresponds to the variable u and the subsequent dynamics corresponding to v we propose without claiming full generality an approach grounded on the assumption that dynamics of the learning component u precedes and is independent of the following dynamics which however also depends on u this assumption is not the most general one but it can cover the modeling of the interaction rates and of the transition probability can account specifically on the said assumption let us now consider the modeling of the interaction rate which requires the definition of different concepts of distance between interacting entities some concepts can be given which can be applied both to the distance between candidate and field particles and to that between test and field particles the hierarchy indicates that interactions within the same fs can be considered in sequence therefore the aforementioned distance can be considered the micromicro distance refers to the individual microscopic states within the same functional subsystems namely u iu p and v jv q where the subscripts p and q refer to the field particles in the same functional subsystem and the micromacro distance refers to the interaction between the individual microstate and the whole fs whose state is defined through a suitable average for instance the mean value then one has that micromacro distances are given by u i e s and v j e s as a consequence the interaction rate can be modeled by assuming that the interaction rate decays with the distance between the interacting entities measured by a specific metrics in more detail the metrics can be obtained by an exponential decay with a distances either micromicro or micromacro from a basic value delivered when the distance is equal to zero symmetric interactions appear if interaction rates depend on the metrics defined above while asymmetric interactions can be modeled by introducing a weight function depending on the localization of the nodes consider now the modeling of the transition probability which models the output of the interaction of aparticles with state u h v k within the ith fs due to interaction with other aparticles as well as with the fs as a whole the aforementioned hierarchy implies that the dynamics of the learning component u precedes and is independent of the dynamics of the social component v whose interaction dynamics however depend on u for this reason the transition probability a is composed of the contribution of two transition probabilities namely the first one modeling the change of the level of knowledge of the candidate particle and a second one which accounts for the subsequent dynamics conditioned by the learning level therefore the transition probability can be given as a factorization of the transition probabilities over the discrete variables u and v the role of exogenous networks can be taken into account by the selection of the functional subsystem to be related to the localization of the nodes as proposed in 4748 here we use discrete probability rather than continuous probability density the problem of the creation of endogenous networks generated by aggregations which is one of the key problems posed in 49 cannot be straightforwardly treated by the approach of this paper as it needs additional work the specific applications treated in the next section aims at showing how the aforementioned general approach can be particularized towards specific case studies in addition it will be shown how the further developments will be motivated by well defined applications it is worth mentioning that a common feature of all applications is the interaction of learning dynamics with a different type of dynamics which precedes or follows learning in mode details three case studies followfirst in social dynamics where welfare policy is an important influence over the learning dynamics underlying the opinion formation second collective learning modifies the mechanical rules by which crowds move lastly collective learning in multicellular systems modifies the proliferative andor destructive interactions in the immune competition case studies towards perspectives the literature critically analyzed in section 2 has enlightened a wide class of possible learning dynamics in view of a modeling approach we do not naively claim that the methodological approach proposed in our paper can cover the aforementioned whole variety therefore we will focus on the main objective of our description namely the modeling of the interactions between learning dynamics and other types of dynamics which can be modeled by kinetic theory methods this statement can be made more precise by selecting three case studies which present different features to show how the approach can be technically developed firstly we show how the learning dynamics related to welfare distribution can lead to a distribution of supportopposition to governments which in turn can even generate radical opposition secondly we refer to the interaction between learning and crowd dynamics namely between learning which leads to mechanical dynamics namely walking strategies lastly we consider the immune competition in heterogenous multicellular systems where learning leads to proliferative and destructive events well defined hints will be given for each of them in view of research programs which might take advantage of the suggestions of this section as we shall see some applications might require further developments of the approach proposed in section 3 as we will critically analyze in the last subsection social conflicts and radical opposition let us firstly consider the modeling of a dynamics where a welfare policy can lead to social conflicts and radical opposition in more detail let us consider the dynamics treated in 8 where a certain welfare policy generates either support or opposition to the government author of the said policy we consider an opinion formation process driven by the learning dynamics by which individuals communicate and learn already the authors in 8 have shown that the modeling approach should account for nonlinearly additive interactions this feature has been confirmed in some subsequent papers that have developed this pioneer idea for instance 50 51 52 the approach of 8 models the sequential interaction of two dynamics wealth distribution which has been treated by various authors eg 365354 and opinion formation has been introduced in 37 and subsequently treated by various authors for instance 5556 a survey of the literature on this topic has been reviewed in 57 the modeling of wealth distribution precedes the modeling of support or opposition to a government our hint is that the modeling approach developed in 8 deserves a revisiting focused on a deep analysis on the role of learning dynamics in particular the following research objectives are proposed 1 modeling the role of the individual learning from the whole population to understand how a certain trend which can be conditioned by the wealth distribution can lead to radicalization of the political contrast 2 modeling the transition which can be viewed as a darwinist mutation from a radical however democratic opposition to a segregation of individuals ready to break laws and bring their opposition up to extreme levels 3 modeling the selection following mutations by an approach which might require the addition of a new fs corresponding to security forcesactions to act against the aforementioned radicalization the learning dynamics presented in 8 were based on simple rules while the modeling of the mutations towards radicalization can be developed by introducing a threshold in the radicalization level which identifies the transition to extremism collective learning and dynamics of crowds the second case study refers to the interaction between learning dynamics which produces social behaviors and the dynamics of crowds which is a mechanical system where human behaviors 44 appear learning can have an important influence over the walking strategy of individuals in the crowd as it is shown in a recent paper 45 where a modeling approach includes the propagation of stress conditions in particular it is shown how stress conditions can modify both the overall dynamics and density patterns inducing the formation of overcrowded zones which is a bad event against safety the modeling approach proposed in 45 is based on tools of the kinetic theory initiated in 43 and further developed in 44 while the derivation of macroscopic equations from the underlying description at the microscopic scale delivered by kinetic models has been obtained 5859 this topic deserves further research developments which might take advantage of the following hints 1 the development of a learning dynamics in a crowd where individuals communicate and learn through small group awareness communications propagate stress which in turn can generate unsafe dynamics 2 an additional interesting example is that of swarms dynamics where communications and learning induce a collective motion with flocking properties 60 such specific interaction between learning and mechanics might generate a motion suitable to optimize the swarm defense against the attack of predators 61 3 collective learning should include nonlocal effects that have not yet been treated in 1 nor in full generality in 45 therefore this research perspective requires further developments of the mathematical theory proposed in section 3 to account for space dynamics and pattern formation multicellular systems and immune competition lastly let us consider the dynamics of the immune system versus cells carriers of a pathology we consider referring to 62 a multicellular system including three populations namely epithelial immune and cancer cells each population has a different internal variable immune cells can proliferate and activate their internal variable which can correspond to the defence ability against cancer cells cancer cells can proliferate and progress towards states with higher pathological states namely by increasing their proliferative ability up to metastatic competence 6364 immune cells have the ability of depleting cancer cells which in opposition can inhibit the defence activity of immune cells the first learning process of the immune cells is the acquiring of immune competence that enriches the innate immunity 65 these complex dynamics have been studied in 626667 which have been inspired by researchers in the field of immunology 68 who motivated their conjecture by the idea that learning dynamics can induce mutations both for cancer and immune cells subsequently the dynamics of competition which ends up with proliferative and destructive events induces selection in particular biologists argue that the learning dynamics occurs not only across the competing species but also within the same population for instance active immune cells can learn from inhibited immune cells and similarly weakly progressing cancer cells can learn from highly progressing cancer cells the following hints are brought to the attention of the interested reader 1 a possible research program would be a deep analysis of the learning dynamics and the related influence over the immune competition 2 the approach with an additional difficulty consists of the modeling of a system with a variable number of interacting living entities as proliferative andor destructive encounters that appear in this dynamics 3 the number of interacting functional subsystem grows in time due to the onset by mutations of new subsystems the mathematical tools proposed in section 3 appear to be consistent with the requirements of the first hint while the second and third hint need developments of new theoretical tools critical analysis towards perspectives our paper has shown how the kinetic theory approach to collective learning can be developed to model cross interactions between learning and subsequent dynamics three specific applications have been outlined focusing on different living systems while possible hints have been given to develop these applications therefore looking at research perspectives it is quite natural to tackle the challenging problems presented in this section by taking advantage of the said hints these applications indicate that the mathematical structures derived in section 3 might need to be further developed to account for some aspects of the darwinist dynamics space propagation and proliferativedestructive events in addition to the above reasoning it is worth mentioning that the approach cannot be limited to modeling but it should also require development of computational tools considering that the approach refers to equations of the kinetic theory monte carlo particle methods appear to be the approach consistent with the structures of these types of equations therefore one has to deal with the development of pioneering works for instance referring to the books 6970 to recent applications reported in 367172 numerical simulations can also contribute to cover however at a heuristic level issues that are not easily tractable such as existence of equilibrium configuration and related stability analysis lastly let us focus on the problem posed by a multiscale vision where macroscale models are derived from microscale models as delivered by kinetic type models a unified approach to this specific multiscale problem has been proposed in 7374 it is a general analytic tool that can be further specialized to a micromacro derivation for the class of systems treated in our paper

this paper is motivated by the perspective ideas proposed in our previous studies where some challenging problems for instance qualitative analysis of the solution to nonlinear problems and micromacro asymptotic analysis where posed our work focuses on the study of the interactions between learning dynamics and other types of dynamics which can be modeled by kinetic theory methods the contents are presented in three parts first a general description of different theories of learning dynamics within the framework of cognitive sciences is critically analyzed with the aim of capturing the main features of the system towards modeling subsequently the class of systems which are the object of the modeling approach is defined by showing how the previous structure can be developed thanks to new conceptual ideas including the concept of symmetric and asymmetric learning towards modeling finally some applications are selected to show how the approach can be methodologically applied

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introduction cardiovascular diseases are the worldwide leading cause of mortality globally the highest cvd mortality rates are found in ukraine russia and centralasia those postsoviet countries like kyrgyzstan with a population of 63 million in 2018 have experienced volatile economic and political transitions that make up challenging socioeconomic conditions for health and wellbeing in the multiethnic population the main risk factors for cvd include physical inactivity obesity unhealthy diet smoking drug abuse hypertension and lipid abnormalities prior studies have shown lower cvd mortality attributable to dietary risk in kyrgyzstan and among central asians compared to east europeans and western asians there are also gender differences as women have lower incidence levels and develop the disease later than men their protective mechanisms against cvd are mainly associated with sex hormone levels as the incidence and severity of cvd increase in women during postmenopause period at the same time gender behavioral differences may play an important role as women visit physicians more often their diseases are registered more frequently whereas men may not visit a physician until it may be too late apart from those various social factors may contribute to differences in cvd incidence individuals with low socioeconomic status experience higher rates of cvd burden and mortality low level of educational attainment is associated with high prevalence of cardiovascular risk factors high cvd incidence and cvd mortality in kyrgyzstan in 2017 the gini coefficient that is a measure of inequality among levels of income was 268 this reflects relatively good equality in income distribution since the country residents have a similar relatively low standard of living it has been indicated that socioeconomic inequalities are more prevalent among minority ethnic populations who have high prevalence of cvd and related risk factors and this inequality is growing globally ethnic minorities also experience more barriers to access a cvd diagnosis poorer recording of clinical data receive lower quality of health care and have poorer health outcomes carson and colleagues showed that ethnicity is an important predictor of hypertension kontsevaya et al found that among kyrgyz women arterial hypertension prevalence was significantly lower than in their russian peers at the same time among kazakh and kyrgyz men systolic blood pressure was significantly higher than in russians it is welldocumented that social factors may moderate stress level chronic psychological stress is associated with a greater risk of depression autoimmune diseases respiratory infections as well as coronary heart disease stress as a complaint is related to anxiety and depression psychosocial factors such as depression and low social support are in turn established risk factors for heart disease and have been associated with high risk of adverse cardiovascular outcomes and mortality among patients with cvd mental distress is associated to social factors ethnicity gender age and disability stress may perpetuate sleep disturbance as complaints in burnout and symptoms of insomnia may lead to poor sleep worry and increase of blood pressure whereas stress fluctuates strongly since it is a necessity in daily life in coping with everyday hassles chronic stress that results in burnout may be a particular risk factor for chronic diseases sleep disturbance is both an initiator and a consequence of burnout and depression as the result of longterm inflammatory processes due to mental distress plaque formation on the vascular walls in atherosclerosis may eventually lead to a cvd event the fact that stress also underlies burnout and sleep disturbance highlights the importance of these conditions on persons with cvd the current study aimed at characterizing different ethnic groups in kyrgyzstan with respect to cvd and the mental distress conditions including sleep disturbance burnout and stress and to investigate the association between cvd and mental distress based on earlier evidence we infer that some ethnic groups are more likely than other to contract cvd the present study tested the hypotheses of the minorities compared to dominant kyrgyz ethnic group being more likely to suffer from cvd andor having higher levels of mental distress following mezick et materials and methods data collection a sample of 694 individuals aged 18 years and older visiting polyclinics and health care centers were invited to participate in a study entitled health status of ethnic minorities in kyrgyzstan we chose five polyclinics in the suburban areas where representatives of minorities mainly reside in bishkek kyrgyzs as a control group were recruited from the same facilities we used a questionnaire with 47 questions to explore the health status behavioral and psychological determinants and prevalence of cvd body mass index age gender education level ethnicity and income informed consent was obtained from participants after explaining the study aims voluntariness of participation and anonymised data processing the respondents answered the questionnaire and could ask for assistance or explanations from the study leader the initial sample included 1200 participants with a response rate of 578 this resulted in 694 respondents we used random sampling stratified for ethnicity age education and gender ethnicity was asked as open question please indicate your ethnicity see also phinney and ong in kyrgyzstan the kyrgyz comprise 733 of the population other major ethnic groups include russians concentrated in the north and uzbeks living in the south small but noticeable minorities include dungans uyghurs tajiks kazakhs and koreans other small ethnic minorities make up 26 of the population following this the participants were divided into six groups based on their ethnicity kyrgyz people kyrgyz functioned as a control group for comparison with the other ethnic groups due to their similarity in religious background and geographical origins we grouped five additional ethnic groups as follows east europeans russian byelorussian and ukrainian central asians uzbek kazakh tatar east asians korean western asians georgian armenian turk and azerbaijan and other minorities dungan and uyghur in the initial sample of 1200 participants we aimed at ethnic group proportions of 40 kyrgyz 20 east europeans 20 central asians 5 east asians 5 western asians and 10 other minorities the final sample of respondents consisted of 313 kyrgyz 344 east europeans 164 central asians 55 east asians 33 western asians and 91 other minorities regarding age groups we aimed at equal proportions of age groups resulting in 249 aged 1829 244 aged 3039 173 aged 4049 173 aged 5059 and 161 aged ≥ 60 years regarding education we aimed at the proportions 26 with higher education 68 with high school education and 5 with elementary or secondary school in the final sample higher education was overrepresented 41 and the proportions were 572 with high school education and 16 with elementary education in the final sample male sex are slightly underrepresented the questionnaire instruments the questionnaire used was in the russian language sociodemographic variables were assessed following the guidelines for handling the harmonized questionnaire and anthropometric data were assessed according to the who recommendations we used the question do you have any cvd diagnosed by a doctor to determine any diagnosed cvd coded as any cvd we grouped individuals according to their educational background individuals were grouped according to their bmi as follows bmi 25 kgm² as reference bmi ≥ 25 kgm² as individuals with higher risk the karolinska sleep questionnaire was used to assess sleep disturbance the questions were have you been bothered by the following complaints during the past three months difficulties falling asleep repeated awakenings with difficulties falling asleep again premature awakenings involuntary and disturbedrestless sleep the response options throughout the ksq are never seldom sometimes often most of the times or always the score can range from 0 to 20 the ksq has good reliability construct validity and criterion validity the internal consistency in the current study was good for further analysis the participants were divided into groups that as far as possible constituted the first to third and the fourth quartile 827 individuals with score 08 and the rest with score 9 or higher the physical and emotional subscale of the shirom melamed burnout questionnaire was used to measure burnout the subscale consists of eight items the response scale ranges from 1almost never to 7almost always the score can thus range between 7 and 56 the smbq has good construct validity and reliability the internal consistency in the current study was good for further analysis we divided individuals into two groups according to quartiles 765 individuals with score 825 as low burnout and the remaining with score 26 or higher as high burnout the 10item perceived stress scale was used to measure degree to which situations are appraised as stressful the items assess how unpredictable uncontrollable and overloaded the respondents find their lives the score can range from 0 to 40 the pss10 has good construct validity the internal consistency in the current study was good for further analysis we divided individuals into two groups according to quartiles 756 individuals with score 021 and the rest with score 22 or higher mean scores for all mental distress factors were calculated statistical analysis the statistical analysis was performed using the ibm spss statistics for windows version 230 armonk ny ibm corp differences between ethnic groups in prevalence of cvd sociodemographic outcomes and mental distress factor were tested with chisquare test ttest and posthoc bonferroni test analyses of covariance were conducted to study the associations between prevalence of cvd and levels of sleep disturbance burnout and stress the odds for having cvd in relation to level of sleep disturbance burnout and stress in the various ethnic groups with the kyrgyz as referents were assessed with logistic regression analysis where also gender and bmi were considered confounding variables were only included in the analyses if they correlated with the analyzed variables according to spearman correlation analysis since age was highly correlated with cvd we removed age from further calculations due to multicollinearity the independent variables with a high bivariate correlation should not be included in multiple regression analysis the αlevel was set at 005 ethical concerns ethical approval was received from the research ethics committee of the international school of medicine kyrgyzstan all study participants gave written informed consent in accordance with the declaration of helsinki results there were significant differences in the distribution of cvd and sociodemographic outcomes between the ethnic groups we explored the association between cvd and mental distress in all studied individuals income was excluded from the analyses since too many respondents had not answered that question the ancova on the associations between severity of mental distress and prevalence of cvd showed a statistically significant difference in level of sleep disturbance between individuals with cvd and those without cvd f df 1 p 0001 the difference remained after controlling for ethnic group gender and bmi there was also statistically significant difference in burnout score between the cvd group and the reference group f df 1 p 0001 the difference remained after controlling for ethnic group gender and bmi the difference in stress score between the cvd group and the reference group did not show a trend f df 1 p 0060 the difference remained insignificant after controlling for ethnic group gender and bmi thus in this study sleep disturbance and burnout seem to be associated with cvd but not stress the logistic regression analyses indicated that compared to individuals with low levels of sleep problems individuals with high levels of sleep problems have 216 times higher odds of having a cvd compared to individuals with low levels of burnout individuals with high levels of burnout have higher odds of having a cvd there was no difference in chances of having a cvd among individuals with high level of perceived stress compared to low level of perceived stress group as for the differences in ethnic groups in analysis of burnout and stress compared to the majority ethnic group kyrgyz east europeans had 155 and 152 times higher odds of having a cvd furthermore compared to kyrgyz central asians and other minorities had a tendency for lower odds and western asians and east asians had a tendency for higher odds of having a cvd in case of all mental distress factors however these associations need to be considered carefully considering the small number of representatives in some minority groups discussion this study addressed the differences in cardiovascular health as well as social and psychological determinants in kyrgyzstan as for the prevalence of cvd the results confirm findings of earlier studies showing different cvd pattern among various ethnic groups particularly easteuropeans like russians have been shown to have a higher prevalence of cvd compared to central asians this study indicated significantly higher prevalence of cvd among east europeans and western asians compared to kyrgyz people furthermore compared to these groups the prevalence of cvd was significantly lower among central asians and other minorities this may be explained by the tendency of east europeans and western asians compared to kyrgyzs and central asians and other minorities showing lower cvd mortality attributable to dietary risk including less alcohol consumption we also clarified the levels of mental distress factors among the ethnic groups in kyrgyzstan based on studies of salyers and bond mezick et al grandner et al and slopen et al we expected ethnic differences in burnout and sleep disturbances however in the current study the levels of burnout or sleep disturbance did not differ among ethnic groups whereas such differences by ethnic groups have been shown in other contexts vice versa in this study the mean score value of stress was lower among east asians and other minorities than among the kyrgyzs east europeans and central asians this suggests that the majority population kyrgyz does not stand out as having particularly better mental health than the other ethnic groups the conclusions on the ethnic differences in burnout and sleep disturbance differ from those from studies in the us thus the present finding that in kyrgyzstan compared to other ethnic groups the majority of the population kyrgyzs do not stand out having better mental stress outcomes can be explained by the lower economic status of this group furthermore the higher rate of mental stress in kyrgyzs east europeans and central asians may be attributed to the fact that unlike these ethnic groups east asians dungans and uyghurs have kept their religious practices throughout soviet time till currently and religious practices have been associated with positive mental health outcomes the ancovas showed significantly higher levels of sleep disturbance and burnout in the cvd group compared to the referent group this difference remained significant after in our logistic regression analysis for burnout and stress we could see significantly higher odds of having a cvd among east europeans compared to kyrgyz and a tendency for lower odds compared to central asians and other minorities compared to kyrgyz thus next to the level of mental distress gender and bmi specificities in ethnic groups may be associated with the higher prevalence of cvd the mechanisms behind the effect of ethnic group for mental distress factors and cvd needs further exploration the crosssectional design of this study does not enable to test of such cause and effect whereas ethnic group can be expected to be a cause rather than effect in this context the associations can well be bidirectional we believe that some of our results may be explained by insufficient number of minority participants despite stratified random sampling ethnic groups differed significantly in age gender and education the invitations for participation directed at patients visiting polyclinics and health care centers cannot be expected to have resulted in a fully representative sample of participants which compromises the representativeness of the findings in particular regarding the prevalence rates since results on prospective selfreported assessment of mental distress such as sleep disturbance and burnout lack in consistency there is a need for further assessment as well as psychophysiological evaluation we also asked the participants about having any cvd diagnosed by a doctor rather than using hospital records this might have caused diagnosis bias even if we specified cvd diagnosed by a doctor nevertheless the current study is one of the very few studies of health inequality among ethnic minorities in central asia the current findings add value to the existing bulk of knowledge of mechanisms mediating the relationship between cultural mental stress factors and cvd the present use of selfreported cvd and mental distress may in future research be complemented by hospital records of cvd diagnosis and psychophysiological measures related to distress conclusion this study suggests that kyrgyz people have lower prevalence of cvd compared to east europeans and western asians in kyrgyzstan and higher compared to central asians and other minorities in studied sample in kyrgyzstan individuals with relatively high level of sleep disturbance and burnout more likely reported suffering from cvd next to the mental distress factors gender and bmi the characteristics of ethnic groups may be associated with the higher prevalence of cvd as there were higher odds for cvd among east europeans compared to kyrgyz the high prevalence rates indicate the need of better diagnosis and treatment of cvd and burnout as well as improving sleep quality with public health measures including stress management restful environment increased physical activity and better nutrition based on the present and previous study outcomes it can be concluded that there is a need for the development of a relevant approach in mitigating sleep disturbance and preventing burnout in the general population not only in specific ethnic groups data availability statement the datasets generated for this study are available on request to the corresponding author ethics statement ethical approval was received from the research ethics committee of the international school of medicine kyrgyzstan all study participants gave written informed consent in accordance with the declaration of helsinki 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 copyright © 2021 azfar dzhusupov orru nordin nordin and orru this is an openaccess article distributed under the terms of the creative commons attribution license the use distribution or reproduction in other forums is permitted provided the original author and the copyright owner are credited and that the original publication in this journal is cited in accordance with accepted academic practice no use distribution or reproduction is permitted which does not comply with these terms appendix

the purpose of this study was to characterize different ethnic groups in kyrgyzstan regarding cardiovascular disease cvd and mental distress and to investigate the association between cvd and mental distress the mental distress was measured in terms of sleep disturbance burnout and stressa crosssectional study was carried out among six ethnic groups in kyrgyzstan aged 18 years and above the sample was stratified for age education family status and income we used the karolinska sleep questionnaire to assess sleep disturbance the physical and emotional subscale of the shirom melamed burnout questionnaire to assess burnout and the 10item perceived stress scale to assess perceived stress results the distribution of cvd differed significantly between the six ethnic groups with higher prevalence among east europeans and western asians and lower among other minorities and central asians in all ethnic groups in kyrgyzstan individuals with cvd had increased odds of sleep disturbance and burnout there was a significant difference in burnout and stress between persons with and without cvd in kyrgyz and east european ethnic groupsthere was a significant difference in burnout and stress between persons with and without cvd in kyrgyz and east european ethnic groups in addition to cvd prevention mitigating sleep disturbance and preventing burnout in the general population should be aimed at in public health measures

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introduction technology develops along with the development of human intelligence including conventional technologies which have now begun to enter the digital realm digitization is a necessity that must happen todays society is forced to enter and use digital technology including television the digitalization of broadcasting is not only happening in indonesia but has been decided by the international telecommunication union since 2006 the united states has already carried out aso in 2009 followed by japan in 2011 and china and korea in 2012 aso has been carried out by several asean countries such as brunei darussalam which started the migration in 2014 thailand and the philippines switched to digital channels in 2015 and malaysia began to switch off in 2017 this was stated by the indonesian national television association at a seminar at universitas diponegoro in 2018 the digitization of television in indonesia has been prepared more than 12 years ago in 2009 indonesia has prepared a framework for the implementation of a digital broadcasting system which was inaugurated in 2010 by president susilo bambang yudhoyono however the digital television migration process in indonesia did not go well because of the conflict of interest between private television and regulations that were not yet strong on november 2 2022 the government has discussed the analog switchoff meaning that the public will no longer be able to enjoy television broadcasts using the analog system since 2018 the government has announced that it will conduct aso so that people can enjoy digital television broadcasts mass media must keep up with the digital era with various adjustments starting from the structure of the media content and production technology so that people can enjoy them according to their needs the fundamental problem with digital television migration is the reluctance of television business actors to migrate and the absence of a legal but now the job creation law seems to force migration to take place in 2022 the government has determined that indonesia will run a digital television system with dvbt2 or digital video broadcasting terrestrial second generation this government program requires support from the public so that it can run well people can buy televisions with specifications for digital devices or continue to use analog televisions with the help of a converter in the form of a set top box this tool will help the community to convert analog signals to digital so that people can still enjoy digital broadcasts using old television sets unfortunately not many people know about broadcasting digitization during the pilot period which was run by tvri central java since 2016 only 38 of the total area in central java covering an area of 32548 km so that some areas such as purworejo sukoharjo solo magelang wonogiri and surrounding areas have not been able to enjoy digital broadcast trials broadcasting digitization is an effort that must be made to improve the quality of broadcasting in indonesia the community as an important element must follow and support this program for the benefit of information technology in the future many studies have been conducted on digital television most of them raised the issue of media management and just a few discussed the implementation of digital television at the community level this study aims to see the effect of information exposure in the mass media and the level of public knowledge about digital television on peoples decision making to adopt digital television theoretical framework the diffusion of innovation theory explains the process of an innovation being discussed through certain communication channels at any time to a person and or group of members of a particular social system according to rogers diffusion of innovation can be said as a form of communication that is specifically related to the spread of messages which include new ideas new innovations or new creations to new users or loyal users this study sees digital television as a new innovation that will be implemented in indonesia where previously indonesian television used an analog system and in the future it will use a digital broadcast system the innovation must be communicated to the community so that the community can accept and be ready for the novelty there are four elements in the theory of diffusion of innovation proposed by rogers namely innovation the main object in the form of ideas actions or goods that have the nature of novelty in a particular society or group in this study digital television is the element of innovation that will be implemented in indonesia communication channel is a tool to send information about innovation to the public usually the communication channel is a medium whether print media electronic digital or direct communication patterns the government is currently doing a lot of socialization regarding digital television and analog switchoff both through print media broadcast media and digital media in addition socialization in the regions has also been carried out by the government time is a very important element to see the pattern of technology adoption in society the period of time in making innovation decisions starting when the government as a source of information conveys information about digital television to the public until the community confirms that they use digital television this time element will determine whether the research subject is an early adopter or a late adopter the social system is seen as a set of distinct and interrelated units and has a variety of roles elements of this social system include community culture local government and influential figures who will determine the community to accept or reject innovation research method the research method used in this research is included in the positivism paradigm the researcher used a quantitative approach by looking at the effect of exposure to information about digital television and the level of public knowledge about digital television on decisionmaking to use digital television the researcher used 120 respondents who were taken from six exresidencies in central java by using a stratified sampling technique respondents filled out the questionnaire which was distributed via the google form link hypothesis research results and discussion respondent data in this study 120 respondents were selected based on the slovin formula with the number of families in central java as the population researchers divided the respondents based on the area of residence in each exresidence in central java which consisted of semarang pati kedu tegal banyumas and solo raya with 20 respondents each respondents are heads of families who have the power to make a decision to accept or reject digital television innovations effect of exposure to information regarding digital television on decision making adopting digital television the government takes various ways to provide information to the public regarding the migration from analog television to digital various messages conveyed by the government through print electronic and digital media are expected to have an influence on peoples decisions to adopt a digital broadcast system the table below shows the effect of exposure to mass media information about digital television does not affect the decisionmaking of the people of central java to use digital television this is contrary to the expectations of the government where the socialization carried out is expected to make people switch to using digital television it shows in parameter estimate x 1 to y as shown in table 1 the quality of a research result can be seen from how the design of the model has been prepared by the researcher based on the test of parallel lines carried out the results show the number 0620 meaning that the hypothesis is accepted the model and the relationship between these variables are relevant and appropriate by using the logit equation so this research model and the link analysis function used are appropriate the influence of digital televisions level of decision making on adopting digital television in this research on the adoption of digital television the researcher also looked at the variable level of community knowledge on decision making to adopt an innovation in the previous variable the researcher saw how information exposure by the media was expected to influence decision making the results shown were just the opposite namely the two variables had no effect the public is expected to be educated and have good knowledge about digital television so that they want to use the digital broadcasting system however the table of results of this study shows that the level of public knowledge about digital television does not affect peoples decisionmaking to use digital television this parameter estimate table shows its significance value the effect of the independent variable exposure to information about digital television shows 0484 005 and the level of public knowledge about digital television shows a significance of 0640 005 on the dependent variable of decisionmaking using digital television which has a significance of 0034 005 this figure shows that the factor of exposure to information about digital television and the level of knowledge about digital television does not have an influence on peoples decisionmaking to adopt digital television so the hypothesis is rejected the implementation of broadcast digitization in indonesia based on the order of the job creation law analog switched off is carried out a maximum of two years after the work creation law is passed until november 2022 analog television has been turned off by the government and cannot be accessed in several regions in indonesia this is what makes indonesian people adopt digital television despite low information exposure and a low level of public knowledge of digital television the decision to adopt digital television is high this migration also does not pay attention to the level of community knowledge whether people are ready or not they will still be forced to adopt digital television decisions making the digitalization of television that took place in indonesia which was carried out in 2022 was a big step in indonesian television this digitization is in accordance with the theory of diffusion of innovation which explains the process of an innovation being discussed through certain communication channels at any time to a person and or group of members of a particular social system according to rogers television digitization is an innovation that is discussed or discussed through communication channels which is carried out by people who are television audiences the diffusion theory of innovation is related to social systems social systems have another important influence on the diffusion of new ideas television digitization is also influenced by the existing social system in society because in addition to the readiness of tools and networks the readiness of the social system that supports it must also be considered innovations can be adopted or rejected by individual members of a system or by the whole social system which can decide to adopt innovation by collective decision or authority television digitization that occurs in indonesia is a technology that must be adopted by all indonesian people in enjoying television broadcasts which will be carried out starting in 2022 this digital technology must be carried out because it is mandated by law so indonesian television audiences are indirectly forced to adopt television digitization the transition from analog to digital carried out in indonesia does not fully pay attention to the readiness of the community but pays more attention to the readiness of television digitization technology and the readiness of devices that must be installed on analog television in order to capture digital signals clearly public knowledge about television digitization is still minimal so there are still people who are digitally stuttering people who are digitally stuttered still have not accepted the transition from analog to digital because people have to learn new things and have to buy more equipment in order to enjoy television broadcasts however the mandate of the law that forces analog television to be turned off makes people who are digitally stuttered also forced to adapt to the current situation so they are forced to learn about digital television and buy equipment to receive digital broadcasts decisions about the adoption of new technological innovations are not entirely in the hands of the wider community but rather are determined by several parties who have power over the technology such as in digital television the community also has no choice or does not have the power to choose whether to remain in the country analog television or switching to digital the current adoption of digital television innovation emphasizes that the government imposes on the public the transition that people must switch from analog to digital quickly without having sufficient knowledge about how digital adoption works social systems have another important influence on the diffusion of new ideas innovations can be adopted or rejected by individual members of a system or by the whole social system which can decide to adopt innovation by collective decision or authority according to rogers there are several kinds of decisions in adopting innovation including authority innovation decisions a decisionmaking system in which the choice to adopt or reject an innovation is made by relatively few individuals in the system who have power status or technical expertise the individual members of the system have little or no influence on innovation decisions he just implemented his decision in the phenomenon of television digitization it is more appropriate to be in the authority of innovation decisions this means that the decision to adopt or reject the digital television system is made by the adoption unit relatively few in the system that has more power people have little choice in adopting a digital television system or not using television because in the existing system the decision is taken by the party that has the power in this case the government people seem to have no other choice but to follow the decisions made by the government as the ruler of the existing regulations in indonesia in fact if you look at the digital technology used by digital television it still uses frequencies where these frequencies should belong to the public and the government has the mandate to utilize these frequencies so that indonesian people can get benefits according to the needs of these communities frequency belongs to the people of indonesia so if television uses that frequency television must also be responsible to the people of indonesia if there is a transfer of technology related to television and the television still uses frequency this change or migration must also be adjusted to the readiness of the community and must not be forced by the community to adopt the technology in addition the community is also given a choice so that the community can choose whether to adopt a new technology or stick with the old technology while still being informed and educated about the benefits of the new technology the communitys response to the digitization of television the digitization of television in indonesia is taking place in regions throughout indonesia the broadcast transition process known as migration or analog switchoff has been in process since november 2 2022 therefore migrating to indonesias digital broadcasting system is a mandate from the law that must be implemented in recent years the government through the ministry of communication and informatics has carried out socialization on broadcast digitization including through public service advertisements in various media television print media and online media and organizing seminars both virtually and in person the goal of course is for the public to be prepared when the digital broadcasting era has officially come into force a survey conducted by kompas on 2326 november 2021 involving 509 respondents aged at least 17 years from 34 provinces in indonesia noted that half of the respondents stated that they had heard that in november 2022 or next year indonesia would implement a digital television broadcast reception system including gen z as the youngest generation around 481 have ever heard of it and the oldest generation baby boomers 472 a large proportion of other respondents stated that they had not heard of the program this indicates that the socialization process carried out by the government has not been evenly distributed and comprehensive to the community the people who have heard this generally come from middle and highereducation groups so it can be said that socialization is still elitist among established people in november 2022 the migration process in indonesia has been underway but the government must accept that the publics readiness to receive digital television is low because based on the results of a survey conducted by the ministry of communication and informatics and kompas the level of public understanding and knowledge of digital television broadcasts is low namely 345 and the use of analog television still dominates with a percentage of 69 this happened because even though people had heard or knew about the transition to digital television broadcasts most people of various ages stated that they could not receive or play digital broadcasts either directly via television or with additional settop boxes in addition to this digital broadcasting technology also requires special expertise from its users in operating the equipment including repairing if there is damage this adaptability skill is closely related to human resources who must follow and be able to synergize with the move to the digitalization era someday broadcast media will all use digital platforms operators who currently technically still operate a lot of analog technology need to be given guidance and training to adapt to digital technology based on the results of research conducted by abraham regarding the publics response to television migration in the kalimantan area the attitude of respondents towards the migration of analog to digital tv for the south kalimantan region 175 respondents and central kalimantan 191 respondents while the attitude of respondents who were not interested constrained for south kalimantan was 65 respondents and central kalimantan 49 respondents respondents who stated that they were interested tended to be because the picture and sound quality of digital tv was better even though the tv was moving and were not constrained by the weather or tall buildings and the costs required to get digital tv broadcasts were not considered an established society does not think about costs but rather the functions and benefits of digitization which can improve the quality of television images and shows unlike the research conducted by kominfo and kompas the research showed great results namely 87 this shows that the community does not really care about socialization and media exposure campaigning about migration to digital television broadcasts the community responds by simply following the technological changes that occur these results prove that television media is still one of the mass media favored by the public in obtaining information and entertainment even for certain groups for example in generation y and baby boomers television is the dominant medium for obtaining information these people also still trust television more than other media as a source of information the publics response seemed not to worry about its adaptation because digital over the top content such as youtube is already familiar with the community and has changed peoples viewing and entertainment patterns so far a challenge in itself for digital television broadcasters is to be able to present quality content so that viewers will still like it even though the content is on different frequency bands digital broadcasting uses a digital frequency spectrum that propagates through the air while digital and multimedia content is distributed via the internet network basically the two platforms are different but between media compete for an audience or audience market share the public needs to prepare for the migration to digital television in the past month many people have welcomed the digital broadcast migration by purchasing a set top box a converter that can convert analog broadcast systems into digital ones the rules for enforcing digital tv have been recorded in law no 1 of 2022 concerning job creation as stated in article 72 point 8 which states that the deadline for stopping analog tv broadcasts is no later than november 2 2022 conclusion digital television migration in 2022 is one of the priority policies so whether the community is ready or not analog switchedoff will be executed the results of this study indicate that there is no significant effect of exposure to information about digital television and the level of public knowledge about digital television on peoples decisionmaking in adopting digital television further research is expected to be able to take variables related to the nature of government policies so that it will increase the scientific repertoire in the field of digital technology adoption to see the efficiency of policies similar to digital television migration researchers do not only look at the realm of program socialization dan public readiness but it also focuses on the urgency of the policy

this study aims to see the effect of information exposure in the mass media and the level of public knowledge about digital television on peoples decisionmaking to adopt digital television in 2009 indonesia prepared a framework for the implementation of a digital broadcasting system which was later in 2010 however the migration process for digital television in indonesia did not go well because of the conflict of interest between private television and regulations that were not yet strong the theory of diffusion of innovation from everett m rogers is used to provide an explanation of the pattern of adoption of new technologies in society this quantitative study will measure the effect of exposure to digital television information and the level of public knowledge as independent variables and decisionmaking to adopt technology as the dependent variable in this study 120 respondents were selected based on the slovin formula with the number of families in central java as the population as a result the effect of these variables is not significant in a score of 0034 005 digital television migration policy is a priority policy with authority innovation decisions it started in the uu cipta kerja which states that indonesia must immediately switch analog switched off for a maximum of two years the communication strategy to invite the public to use digital television is no more effective than the policies of the authorities in law so that the readiness and knowledge of the community will not affect the decision to adopt digital television or not

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introduction with an estimated 23 million hiv infected persons india has the third largest hiv burden in any country in the world 1 one of the goals of the current third phase of national aids control program in india is to halt and reverse the hiv epidemic by 2012 by implementing an integrated strategy focusing on prevention care and treatment of hiv aids 2 this goal can be achieved by maintaining the primary prevention continuum effectively tracking the hiv incidence in various subpopulations and implementing appropriately evaluated prevention and therapeutic interventions projections for the year 2031 marking 50 years of aids pandemic have indicated that almost three times the current resources will be required to control the epidemic by focusing on high impact tools efforts to attain behaviorchange and efficient and effective treatment 3 all such efforts would require high level of utilization of services and programs by the stakeholders and their continued participation in the program retention in prevention programs cohort studies and clinical trials is very critical and yet can be very challenging the losses to followup might result from participants loss of interest inadequate oversight by the study investigators or absence of builtin mechanisms for tracking the study participants being lost 4 recent studies have shown that in resource poor countries investigators can achieve high retention rates over long followup period in marginalized or hard to reach populations by employing special efforts which are expensive and management intensive 45 health program managers and research scientists have to take necessary steps to ensure that their clients return to the health facility at the assigned time points hence understanding of dynamics of retention of clients is likely to help in planning measures to retain people in prevention programs and research settings requiring long followup such as cohort studies and clinical trials our longterm prospective study provided an opportunity to estimate levels of retention and their predictors using a modeling approach in the context of various hiv prevention and research program related scenarios such as those described below we present three possible scenarios in the area of hiv prevention and research wherein retention is crucial 1 primary prevention through voluntary counseling and testing we hypothesized that high uptake of voluntary counseling and testing services for hiv an important primary prevention strategy of the national aids control program of india would contribute to reliable estimation of hiv burden in various subpopulations and may guide in deciding strategies for secondary prevention and control of aids we studied factors affecting retention in the three hiv prevention and research scenarios described above among men enrolled in a high risk cohort of patients having current or past history of sexually transmitted infections in pune india we explored demographic behavioral and biological factors that might predict retention in the modeled scenarios of primary prevention programs cohort studies and clinical trials methods ethics statement the cohort studies were approved by the national and international scientific ethics and regulatory committees or boards of national aids research institute india and johns hopkins university usa all participants were enrolled after obtaining written informed consent as approved by the ethics committee between 1993 and 2002 as part of collaborative studies between national aids research institute in pune india and johns hopkins university in the united states of america cohort studies were undertaken in the industrial city of pune located in the high hiv prevalence western state of maharashtra in india using this dataset we carried out casecontrol analysis to study factors affecting retention of clients in hiv prevention research and programs the cases in the three distinct modeled scenarios were selected from the cohort of male sti clinic attendees the overall aim of the parent cohort study was to prepare sites and generate baseline data for undertaking phase i ii and iii hiv prevention clinical trials men with current or past history of sti female sex workers and non sex worker females attending sti clinics were enrolled in the parent cohort study after they received their hiv negative report thus all those who tested hiv negative were offered enrollment in a longitudinal study requiring quarterly visits for a period of two years as described in our previous papers 67 in this paper we describe predictors of retention among men in the sti cohort using casecontrol analysis three modeled scenarios of primary prevention cohort study and clinical trials were identified as described previously statistical analysis univariate and multivariate conditional logistic regression analyses were performed to identify demographic behavioral and biological factors associated with retention in the three modeled scenarios respectively the comparison of baseline characteristics of individuals in all the three scenarios was done using chisquare or fishers exact test whichever was applicable the variables that were found to be significantly associated with retention in the univariate models were retained in the multivariate models as an exception the variable number of fsw partners although not significant in the univariate model was retained in the multivariate model due to its known relationship with retention 89 forest plots in excel software were used to generate figures for multivariate analysis 10 data was analyzed using intercooled stata version 100 results between 1993 and 2002 a total of 14137 individuals visited the sti clinics in this study of these 10801 were men 3252 were women and 83 were eunuchs or transgenders of all the 10 801 screened male sti patients 8631 were found to be hiv uninfected who were enrolled in the parent cohort study the present case control analysis is restricted to these enrolled men most of the men were employed belonged to hindu religion were living with their families and nearly 50 were ever married more than half of these men reported history of alcohol consumption and 84 reported having fsw contact in the lifetime the median age at initiation of sex among them was 19 years thirty two percent of the men presented themselves with the diagnosis of genital ulcer disease profile of men in case control analysis in three modeled scenario a total of 1286 940 and 896 cases and equal number of matched controls were considered in three respective modeled scenarios of primary prevention cohort study and clinical trials cases and controls differed significantly for various baseline demographic and behavioral characteristics predictors of retention in scenario 1 primary prevention marital status education employment diagnosis of gud and diagnosis of any sti were found to be associated with retention in the univariate analysis in the multivariate analysis men who were married and monogamous employed and those with the clinical diagnosis of gud were less likely to return for the follow up visit in contrast male sti patients reporting higher level of education and those who had more than three fsw partners were more likely to report back for followup predictors of retention in scenario 2 cohort study in the univariate analysis marital status education employment alcohol consumption and involvement in sex work were observed to be associated with retention in the multivariate analysis men who were married monogamous employed who gave history of alcohol consumption or those who were involved in sex work were 30 less likely to be retained in the cohort study all these variables were found to be independent predictors of lower retention however men who were educated to high school and beyond were almost 2 times more likely to be retained in the cohort study scenario predictors of retention in scenario 3 clinical trials marital status living away from the family education employment alcohol consumption number of fsw partners age at first sexual intercourse and diagnosis of sti were significantly associated with retention in the clinical trial scenario in the univariate analysis in the multivariate analysis independent predictors of retention were living away from the family being employed and habit of alcohol consumption more educated male patients or those who had more than three fsw partners or those who initiated sex at an older age were almost 15 times more likely to be retained and maintain rigorous followup schedule of a clinical trial scenario discussion we have used data from large cohort studies on sti patients in pune india in modeled scenarios to study the extent of retention and determinants of retention in male sti patients that constitutes an important bridge population in hiv transmission in india 11 we have identified demographic behavioral and biological factors that might predict adherence non adherence of male sti patients to suggested visit schedules we expect that this knowledge would be very useful to design specific strategies that might assist in optimizing retention in hiv prevention research and programs it is possible to identify potential defaulters for retention and implement appropriate interventions this might be less expensive than tracking patients or research participants after enrollment being employed was a common predictor of lower retention across all the three study models level of education showed likelihood of retention across all three modeled scenarios education level among high risk men in india is low 12 13 additional efforts are required to be made for the less educated or illiterate men to effectively retain them in primary prevention programs and clinical trials similar observations have been made in other studies among men who have sex with men 14 15 16 our observation also corroborated with a similar observation in nimh hiv prevention trial 17 as majority of vct center attendees in the government sector facilities in india are less educated 18 special efforts to improve their retention in primary prevention will be required additionally we observed that retention was less among employed men although the education level is expected to be high among them paucity of time could be the logical limiting reason for employed men to come for repeated followup visits as reported by several investigators 19 20 21 to facilitate retention it might be necessary to keep the health facilities and research clinics open and available out of routine work hours presence of gud history of commercial sex work and living away from the family were predictors of lower retention in primary prevention cohort study and clinical trial models respectively alcohol consumption predicted lower retention in the cohort study and clinical trial models while the married monogamous men had lower likelihood of retention in the primary prevention and cohort study models it is well known that in therapeutic programs benefits are generally immediate and more readily visible in contrast success of prevention programs lies in better sustained and prolonged utilization of services which indicates retention needs retention in primary prevention and allied research is expected to be dependent on many factors and strategies such as retention counseling quality of delivery of programmatic and research activities and participant related factors such as motivation costs and time required to be spent by them as the prevention programs mature and new prevention trials are undertaken the need to identify potential drop outs has to be addressed on priority optimizing retention of the endusers is crucial for assessing efficacy 22 and hence strategies should be considered to address various factors influencing retention during implementation of prevention programs and research predictors of retention identified in the study could be used for developing an instrument to identify the clients who are likely to fail to return for required followup visits either in prevention program or in prevention research using such an instrument could be a cost effective strategy to minimize dropouts rather than using expensive measures to track participants or patients who are lost to followup later it has been suggested that both prevention and adherence science need to expand beyond individual boundaries to learn more about motivational and structural strategies that can be applied to large populations so that prevention technologies have adequate time to prove useful when implemented in the communities 5 therefore it is relevant to explore individual factors as well as those related to individuals family or societal environment that can prevent retention in prevention or research programs poor sexual health seeking behavior among men despite their high risk behavior poses a grave challenge 23 we observed that married men who were monogamous were less likely to be retained in prevention programs and cohort study scenarios in this study the precise reasons for this observation may have to be explored through qualitative studies important role of spouses in mens health seeking has been reported 24 several studies have also reported that men who are living away from spouse as well as divorced or single individuals have high risk behaviors 12 and higher dropout rate from the offered prevention umbrella 25 26 27 28 our observation that men who were living away from family were less likely to be retained in the clinical trials scenario provides supporting evidence to this possibility all these observations are strongly suggestive of better health seeking by men having family support we feel that couple centered approach and involvement of female partners in male oriented programs may contribute to the success of program for men however this approach has an inherent limitation that men will have to share information about their health and sickness with their spouses counseling sessions in programs and research could focus on specifically discussing the role of spouses and families not only in improving health seeking but also in keeping up with the visit schedules of programs or studies they are participating in among the behavioral characteristics those men who reported having more than three female sex worker partners were more likely to return for followup in the primary prevention and clinical trial scenarios this probably reflects mens self perception about their risk behavior health seeking in terms of regular and frequent follow up is perhaps better among men practicing high risk behavior focused attention would be required to be given on men reporting high risk behavior less frequently there is an opportunity to effectively intervene to achieve behavioral change through prevention programs in india male commercial sex work is all but invisible and not much is currently known about the status of male sex workers although some studies have reported high hiv prevalence among them indicating a need to develop new 29 innovative interventions targeted towards men in commercial sex work in the present study among male sti patients men reporting commercial sex work were less likely to be retained in the cohort study scenario this is a high risk population and a reliable estimate of hiv incidence in this category of men is an important public health need additionally this population would also be targeted for phase iib or iii studies of hiv prevention technologies and their retention in future clinical trials would be very critical lower age at sex initiation has been reported to be associated with early hiv infection in this cohort 30 hence emphasis should be given on targeting younger men in prevention programs and ensuring their continued retention in the programs to sustain safer behavior alcohol intake has been reported as a predictor of nonretention in several studies 173132 it was no surprise to find that men who gave a history of alcohol consumption were less likely to be retained in our study as well long term commitment might be a challenge in cases of alcohol addiction it might be important to emphasize on identification of alcohol consuming behavior at the entry point of prevention settings and making special efforts to ensure retention of alcohol consuming individuals under the hiv prevention umbrella the diagnosis of gud was an independent predictor of return for a followup visit within 3 months of enrollment ie primary prevention scenario this observation has specific public health significance because it provides opportunities and complete treatment of gud and appropriate counseling for behavior change we have already reported decline in hiv acquisition risk with decline in guds 7 guds are visible or noticeable sti that could motivate a person to seek further medical advice and hence such individuals are probably more likely to return to the study clinics however it has been reported that nongud stis are also associated with high hiv prevalence 33 34 hence it is advisable that men with clinically invisible or nonapparent stis should also be targeted for hiv prevention interventions and retention counseling interactive counseling approaches directed at a patients personal risk the situations in which such a risk is likely to occur and the use of goalsetting strategies are effective in sti hiv prevention 35 shepherd et al 36 have provided evidence that by enhancing access to treatment and interventions through mechanisms such as counseling education and provision of condoms for prevention of stis especially gud among disadvantaged men the disparity in rates of hiv incidence could be lessened considerably as part of the clinical interview healthcare providers should routinely and regularly obtain sexual histories from their patients and plan retention management measures along with implementing measures for risk reduction it is important to ensure that the clients continue to practice safe behavior through sustained followup we recommend that counselors working with participants and beneficiaries of research studies and program should specifically take into consideration clients occupation current marital relationship habit of alcohol consumption possibility of nongud sti and identify cases that may have a potential for being lost to followup this strategy may prove to be cost effective less cumbersome and easier to ensure high retention in future the identified predictors in this study could be used to develop a counseling checklist with measurable indicators of failure in retention such a tool would require validation studies in prevention programs and clinical trial settings the recruitment of participants in this study was through public sector based sti clinics which is a limitation for generalizability of the findings the profiles of clients visiting the public and private sector facilities available are known to be different 37 38 since vct was primarily offered in a research context in this study lessons learnt may have some limitations in terms of applicability to primary prevention programs rolled out to masses hence the predictors of retention identified in this study will have to be understood appropriately in context of the patients receiving health care in other facilities secondly the study essentially involves men and in india men are not only the key decision makers in the community and families but also the major contributors to transmission of hiv in india 2039 the national family health survey iii data 40 in india has shown that 1015 of indian men are at risk of hiv infection hence studies to identify predictors of retention among men gains significance however the predictors of retention among women are likely to be different and they must be explored we conclude that achieving high levels of retention and preventing drop outs was a challenge in case of all the three scenarios of primary prevention cohort studies and clinical trials the knowledge about identified predictors of suboptimal retention could be useful in developing appropriate retention checklists or tools in case of the abovementioned prevention and research programs to minimize potential dropouts

background retention is critical in hiv prevention programs and clinical research we studied retention in the three modeled scenarios of primary prevention programs cohort studies and clinical trials to identify predictors of retention methodologyprincipal findings men attending sexually transmitted infection sti clinics n 10 801 were followed in a cohort study spanning over a ten year period 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 in pune india using preset definitions cases with optimal retention in prevention program n 1286 cohort study n 940 and clinical trial n 896 were identified from this cohort equal number of controls matched for age and period of enrollment were selected a case control analysis using conditional logistic regression was performed being employed was a predictor of lower retention in all the three modeled scenarios presence of genital ulcer disease gud history of commercial sex work and living away from the family were predictors of lower retention in primary prevention cohort study and clinical trial models respectively alcohol consumption predicted lower retention in cohort study and clinical trial models married monogamous men were less likely to be retained in the primary prevention and cohort study models conclusionssignificance predicting potential dropouts among the beneficiaries or research participants at entry point in the prevention programs and research respectively is possible suitable interventions might help in optimizing retention customized counseling to prepare the clients properly may help in their retention

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introduction dental caries is the most common chronic disease in both children and adults in the world severely decayed teeth can have a substantial negative impact on childrens health and wellbeing 1 according to who data 6090 of schoolage children around the world have caries additionally in italy dental caries remains a significant public health problem with a high prevalence indeed at 4 years of age 216 of children have caries at 12 years 431 are affected by caries while in the age group between 19 and 25 882 of people have carious lesions 2 since the presence of caries is a very common phenomenon in many patients treated with orthodontic appliances who have poor oral hygiene a lot of innovative methods have been developed to reduce treatment times and caries as a consequence 3 4 5 6 in the last few years several programs of dental health improvement have been realized having great success with the prevalence of dental caries which has been significantly reduced 7 but this improvement seems not to involve the population of young children who are socially disadvantaged such as migrants in whom caries is still highly prevalent 8 9 10 in fact migrant status is still considered a social vulnerability for oral health 1112 in the history of industrialized countries immigration began centuries ago and is radicated in the culture of those countries in the last decades the immigration phenomenon also in countries belonging to the european community has strongly increased in particular due to job requests education escape from armed conflict and poverty or climate change 1314 one of the problems among migrant people is food insecurity due to a sudden change in diet compared with ones previous eating habits which are linked to cultural traditions 15 this factor combined with a low socioeconomic setting and the high simplesugar foods they consume in the host country might increase a number of adverse health outcomes mostly pertaining to children 16 17 18 19 20 the lack of specific nutrients and of healthy diet which are essential components for developing organisms can cause micronutrient deprivation and induce illnesses such as dental caries anemia and rickets indeed economic and cultural factors could also worsen diet with overconsumption of lowcost nutrientpoor products and beverages which are directly related to early childhood caries 21 22 23 24 the american academy of pediatric dentistry defines ecc as the presence of 1 or more decayed missing or filled tooth surfaces in any primary tooth in a child 71 months of age or younger 25 lack of fluoride intake and healthy diet poor oral hygiene and low economic possibilities to access dental care predispose the development of ecc which eventually may lead to pain infection and eating problems 26 27 28 in italy only in the last 30 years immigration from other countries such as asia africa and east europe has undergone a notable acceleration being a fairly recent phenomenon results of a national survey on the oral health status of 4yearold children conducted by campus et al 29 showed significant associations between caries and nationality of the parents on the contrary in another previous national survey of 12yearolds by the same authors there was no ethnicityrelated increase in the prevalence of caries 30 another italian study 31 analyzed the correlation between social vulnerability and the experience of tooth decay in a cohort of children aged 35 years in veneto it was observed that lower social class families children had more experience of tooth decay and this prevalence in the immigrant group was significantly higher than in italian children and caries was found to be almost four times more severe in migrant ones therefore the aim of this study is to assess dental caries experience and provide the estimated prevalence in migrant and nonmigrant lowses families children in italy in order to develop oral health improvement policies for those particular socially vulnerable groups materials and methods data source this crosssectional study was conducted from february 2020 to december 2021 the sample included children aged in the range of 3 to 5 years with a total of 325 migrant children and 389 nonmigrant children the exams were conducted in three charity dental centers supported by caritas italia and in the name of life foundation between may and december 2021 by six pediatric dentist operators three belonging to the department of life health and environmental sciences section of pediatric dentistry at the university of laquila and the three others belonging to the unesco chair in health education and sustainable development pediatric dentistry section at the university of naples federico ii visual and exploratory examinations were performed on dental chairs under artificial light using disposable oral trays containing dental mirrors forceps and explorers without xray assessment all examiners were calibrated at the unesco chair in health education and sustainable development pediatric dentistry section at the university of naples federico ii and the kappa test revealed a final score of k 090 the inclusion criteria were children aged 35 years and families low socioeconomic status the exclusion criteria were presence of severe general pathologies and lack of informed consent considering these aspects 266 migrant children and 301 nonmigrant children were included in the study based on exam data the dmft index was determined for each child following the guideline from the world health organization geneva switzerland that index refers to the total number of decayed extractedmissing due to caries and filled due to caries teeth for primary dentition individualand familylevel variables the outcome variable for this study was the presence of decay experience that is whether a child had at least one primary tooth that was decayed extractedmissing due to decay or filled the threshold for the presence of dental decay experienced in this index is the detection of caries that has caused the enamel of the tooth to be cavitated demographic variables included age gender socioeconomic status and country of origin children were classified as migrants if the mother was from a nonwestern country the others were assigned the status of nonmigrant the parents of all the participants completed a questionnaire to provide information and documentation about family sociodemographic background with regard to the annual income of the family to certify the questionnaire all the parents needed to bring isee certification which is an official document that contains family income and patrimonial information necessary to describe the economic situation of a family in any given year statistical analysis spss 220 was used for statistical data analysis measurement data were represented as mean and standard deviation a mannwhitney u test was used to compare the dmfts means and a chisquared test was used to compare the caries prevalence of the two samples the significance level was set to 005 sampled children with missing values were excluded from analyses and all analyses were based on the subset with complete data on all study variables results among 567 children 266 were migrant and 301 nonmigrant based on gender 285 were male and 282 were female all the families of the children included in the study had low ses as stated in the parents questionnaire therefore that variable was not included in the analysis results table 1 shows that the total percentage of caries in nonmigrant patients aged 35 years was statistically significantly lower than in the migrant group there was no statistically significant difference in the rates of caries between genders within the 35 age range of both groups table 2 presents the data obtained through intraoral examination and shows that the mean dmft index of migrant children was statistically significantly higher than that of nonmigrant children with no statistically significant difference between genders regarding the single values of dmft the mean of the decayed teeth of migrant children were statistically significantly higher than the mean of those of nonmigrant children the mean of the missing teeth was similar with a mean value of 083 for migrant children and 077 for nonmigrant children moreover for the migrant children the mean of restorations was statistically significantly lower than those of nonmigrant children all these values showed no statistically significant difference between genders discussion the aim of this study is to assess the experience and prevalence of dental caries between migrant and nonmigrant families and the prevalence of caries among young children in italy in recent years in industrialized countries the prevalence of caries has significantly reduced thanks to prevention despite this the experience of caries in children remains a public health problem especially in groups with a low socioeconomic level recent studies have shown that the relationship between dental caries and low socioeconomic level is well consolidated while patients with a high socioeconomic level have better oral health 32 other studies have highlighted how the prevalence of caries increases in relation to a low ses in both deciduous and permanent dentition 3334 the reasons for these differences as already mentioned are well known and are linked both to the difficulties in accessing health care and dental care for economic reasons and to the daily management of oral hygiene and prevention as well as to incorrect eating habits furthermore other studies have revealed that dmftdmft values caries prevalence and unmet restorative treatment needs index among migrant children were higher than those among nonmigrant ones 35 in addition the recent covid19 pandemic has been associated with several changes in the maintenance of childrens dental health during the lockdown it was found that children changed their daily habits some authors have pointed out an association between the increase in the frequency of taking snacks and sugary drinks the decrease in the frequency of brushing teeth and the postponement of oral health care to an increased risk of developing tooth decays 3637 during the first spread of the covid19 pandemic most public and private territorial health facilities in most countries were closed the consequences of the suspension of routine dental care and the delay in the management of oral hygiene have led an increase in dental emergencies especially in the pediatric population 38 which was followed by higher access to firstaid facilities for dental emergencies especially in the most disadvantaged categories of the population considering these statements the present study analyzed the oral health status in two groups of children and the extracted results showed that the difference in the mean dmft between the two groups was statistically significant and the oral health was worse in migrant children confirming the relationship between social vulnerability and caries experience in addition to this the prevalence of caries and the dmft were consistently higher than the national mean even for the control group and this is attributable to the fact that the control group is also part of a category of social vulnerability which predisposes to a higher development of caries analyzing the components of the dmft index the migrant children had more decayed and less filled teeth than the control group thus denoting a greater need for dental care and absence of control of the carious pathology therefore the values regarding filled teeth are statistically significantly higher for children belonging to the nonmigrant group and this would mean on the contrary greater control of the carious pathology and greater access to dental care for this group conversely the difference for missing teeth was not statistically significant the results of this study provide a detailed insight into the oral health status of lowincome families migrant and nonmigrant children the results are in agreement with current epidemiological studies the prevalence of caries and the dmft in the socially disadvantaged classes are higher than the national mean in addition migrant children compared with natives have a higher prevalence of caries and a greater need for dental care therefore the present knowledge can be useful to design national epidemiological studies to evaluate the current state of caries in italy to verify the impact of covid19 on childrens oral health even in these highrisk groups featured in this study to be effective these interventions should be easily accessible and engage both children and parents such as implementing communityschool health programs and giving information about preventive and curative aspects another interesting intervention would be to involve women beginning in the gestational period so that they can be taught by several professionals such as dentists dental hygienists and pediatricians about oral health it is really important that pregnant woman have information about oral hygiene techniques about nutrition aimed at the prevention of caries in newborn children and about the importance of the evaluation of a childs oral cavity at 1824 months by an oral health professional all these strategies should be used in order to achieve the goal of zero caries in the pediatric population conclusions this study highlights that children aged 3 to 5 years with a low socioeconomic level show high values of tooth decay moreover dmft values and the prevalence of caries are higher in migrant children than in nonmigrant children therefore we can state that in the lowerincome classes caries disease in primary dentition is still a public health problem today especially in the migrant population it is necessary to evaluate and monitor these situations in order to develop effective programs aimed at improving and subsequently maintaining the state of oral health to intervene promptly and prevent the appearance of dental caries institutional review board statement the study was conducted in accordance with the declaration of helsinki and approved by the ethics committee of the university of naples federico ii italy informed consent statement in this study informed consent was obtained from all the parents of the subjects involved written informed consent was obtained from the parents of all the subjects to publish this paper written informed consent was acquired from the guardians of all the children to publish this document data availability statement the data of this study will be made available after a formal request to the authors author contributions gff rg and sc conceived the protocol contributed to data acquisition and revised the manuscript medf and sc contributed to formal analysis gdf and gdb contributed to the writing review and editing of the manuscript gdf contributed to statistical data analysis and interpretation all authors have read and agreed to the published version of the manuscript

dental caries is a public health problem in children and is more prevalent in lowsocioeconomicstatus groups the aim of this study is to assess the association between migrant families and the prevalence of caries among young children in italy this is a crosssectional study in the age range of 3 to 5 years a total of 266 migrant children and 301 nonmigrant children were examined in three italian charity dental centers all children had families with low ses the dmft was determined by intraoral examination performed by six pediatric dentist specialists to assess their dental health in this study the prevalence of caries 71 and the mean dmft 368 sd 152 of migrant children were statistically significantly higher than the percentage 52 and the mean dmft of the nonmigrant control group 310 sd 165 with no differences between genders for the migrant children the mean 049 sd 032 of restorations filled teeth was statistically significantly lower than that of nonmigrant children 120 sd 048 this study highlights that dmft values and the prevalence of caries are higher in migrant children than in nonmigrant children in addition the control group shows a higher level of dental caries than the national mean

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background in multiple archaeological discoveries since ancient times balinese society has interacted with various ethnic groups the discovery of various ancient artifacts including ancient pottery from india and china strongly supported the claim that bali with its people holds a strategic position in global social interactions 1 the social interaction significantly influenced how balinese culture thrives especially in religion culture and arts hitherto the balinese distinctive culture and skills have developed into tangible and intangible identities it is well presented on balinese tourism which has been indonesias pride in the eyes of the world the balinese workforce is one of the best workers with expertise in tourism recognized by various companies engaged in hospitality services in different parts of the world along with the times a few balinese people migrated out of their homeland to pursue careers overseas they spread to various corners figure 1 4 birds eye view of pura agung santi bhuwana pairi daiza belgia of the world especially to welldeveloped countries for a better chance of living these balinese ethnic groups that spread to various countries are known as the balinese diaspora despite having been far away from their homeland for years the balinese diaspora has strong kinship ties and is fond of their land the condition is arguably due to the strong influence of religion customs and culture which is reflected in the life of the people albeit in their current geographical position according to tempo in 2015 the indonesian diaspora was spread over 90 countries 2 in terms of global quantity the number of indonesian diasporas is smaller than that of chinese diasporas which reached around 70 million people and the indian diaspora which figures at approximately 60 million the figure is however directly proportional to the total population of the two countries jusuf kalla vice president of the republic of indonesia at the opening of the congress of indonesian diaspora iii stated that in terms of population size indonesia has the opportunity to occupy the third position as a contributor to the diaspora in the world however the statistic was outnumbered by the philippines 3 the balinese diaspora spread across various continents including europe the existence of the balinese diaspora in europe for many years has been viewed as a dual role agent they acted as cultural intermediariesagents and tourism agents for bali and indonesia in general balinese art and culture as identity each ethnic group has a distinctive cultural identity related to its respective regions and geographical conditions thus cultural identity firmly adhered to ethnicity or regionalism which was born in each ethnic ground and then socially integrated or coexisting with the hosts in their new habitat cultural identity is a sense of belonging it may refer to a sense of belonging to a particular group a personal conception and perception and related to nationality ethnicity religion social class generation localism or social groups with their cultural characteristics in this context cultural identity is a breakdown of individual and group features that have cultural similarities and can be seen compared to other groups cultural characteristics 5 meanwhile national cultural identity is a mixture of various cultural features owned by individuals and groups that are considered capable of representing the characteristics of a country and all of its people it is visible when compared to the national cultural identities of other countries from balinese hinduisms perspective art has its strategic position art is part of the religious activities of the hindu community in bali when a ceremony or religious ritual is held at the temple the society presents performing arts such as dance musical arts fine arts and literature as part of the peoples expression of gratitude to the higher being temple and others building in bali are designed and erected in such a way as an expression of the aesthetic ethical and religious attitudes following balinese hindu teaching in the spirit of service the dancers perform their skills as a devotion to god almighty the religious nature of the balinese community and the universal teachings of hinduism lead to the proliferation of art much of the art is intended for a particular ceremony or as a complement to a ceremony apart from religious purposes performing art as entertainment is welldeveloping using gamelan instruments in hindu ritual activities represents lord iswaras existence his presence emits spiritual vibrations in the ceremony 6 gamelan creates festivity in some rituals like dewa yadnya pitra yadnya manusa yadnya rsi yadnya and bhuta yadnya is an integral part of the ceremony built by a belgian named eric dombecausens the temple was inaugurated on may 18 2009 dombecausens love of balis uniqueness and cultural traditions motivated him to establish the shrine the temple construction process was carried out in stages thirty balinese undagi were brought to belgium to build the temple and worked on it for two years the temple stone materials were directly imported from the slopes of mount merapi central java these meticulous efforts were made to maintain the cultures authenticity the holy sanctuary was inaugurated simultaneously with taman indonesia a 5hectare indonesian park complex within the 55hectare parc paradisio tourism park area 8 when the balinese hindu religious holiday is commemorated in belgium hundreds of balinese hindus who live in europe such as luxembourg the netherlands england germany france and sweden flock to the temple since early morning this ceremony activity involves members of the banjar consisting of the balinese diaspora who live throughout the european region some prominent groups include banjar bali from the netherlands banjar suka duka from belgium banjar santi dharma from paris sekar jagat from indonesia and hindu communities in luxembourg england germany and sweden the balinese diaspora in europe is dominated by social groups talented in dancing and playing gamelan instruments they represent and subsequently support tourism promotion programs of the republic of indonesia through their traditional religious activities they naturally support the existence of temples in europe such as in belgium hamburg and berlin with their stunning performing dance and percussion art service balinese cultural activities in belgium europe balinese performing art in the heart of a foreign continent balinese dance is divided into three according to each function and purpose wali dance bebali dance and balihbalihan dance the art of wali means a sacred dance this dance functions as a complementary executor in a religious ceremony which is only staged in holy places either the main temple area or places according to custom then the bebali dance or ceremonial dance is closely related to traditional ceremonies serves as a complement for ceremonies ceremonies at temples or outside temples balibalihan dance is all dance that functions as entertainment art a means to express joy a sense of fun and for association 9 10 in 2017 the ceremony was even led by a hindu priest directly escorted from and influenced all aspects of life albeit the unevaded facts thousands of the balinese diaspora and the local citizens respectfully attended the religious movement they came from various cities in belgium to join the ceremony they witnessed balinese art performances enlivened by the pendet and kecak dances by the sekar jagat indonesia of paris group and balinese childrens music by the banjar suka duka group from the netherlands 12 in the tumpek kandang day celebration at the pura agung santi bhuwana the pilgrim celebrates the day to maintain the harmony of life with all living things and the universe representing the core teachings of balinese hinduism hindus always try to teach love to gods creation including livestock and pets as a form of this love balinese hindus have a special day of celebration for animals the event was held in the morning with a prayer ritual and simple ceremonial materials made by the women then from 1 to 3 pm local time a megibung event is held it is a feast where each participant brings their homemade dishes to be shared with others this tradition becomes a routine in every prayer ceremony held at this temple with the hope that megibung can strengthen their unity without being disturbed by caste or clan differences social classes or other disputes besides that pendet rejang janger dance genjek bali the priest ida pedanda dalem putra sibang came from bali to oversee the temple inauguration ceremony in 2017 together with the entourage on occasion the priest performed spiritual cleansing ceremonies including sudi wadani an initiation ceremony for fifteen european citizens who decided to convert to balinese hindu the deputy head of the indonesian representative office kristanyo hardojo representing the indonesian embassy in brussels said that the galungan and kuningan celebrations were among the most important religious festivals celebrated by the balinese hindu community this celebration simultaneously illustrates the tolerance of interreligious life in indonesia where all levels of indonesian society from various religions and cultures can commemorate the holy day together whether in indonesia or abroad he further explained that the existence of the pura agung santi bhuwana is not only a place of worship for hindus but also a venue for promoting indonesian cultural heritages in europe in his remarks the chairman of the belgian hindus association i made wardana said that the balinese hindu community who live in europe could maintain steadfastness by respecting their own culture amidst the onslaught of a global culture he admitted that global influence penetrated all practical activities

the balinese workforce is one of the best workers with expertise in tourism recognized by various companies engaged in hospitality services in different parts of the world along with the times a few balinese people migrated out of their homeland to pursue careers overseas they spread to various corners of the world especially to welldeveloped countries for a better chance of living art and its strategic position in the balinese hindu community is the peoples expression of gratitude to the higher being as part of the religious activities of the hindu community a ceremony or religious ritual held at the temple holy place always showcases performing arts the customs are strongly associated with identity for instance despite being far away from bali the balinese diaspora in belgium commemorated balinese hindu holy days festively in pura agung santi bhuana belgium the balinese hindu diaspora of europe attended the temple ceremony in the early morning the members of the social group banjar performed their service by staging a dance and gamelan orchestra to accompany the holy day ceremony the talented balinese diaspora on dance and play gamelan instruments constitute a significant part of the total population they support the governments tourism promotion programs of the republic of indonesia through their traditional religious activities subsequently they enlivened the existence of temples in europe such as in belgium hamburg and berlin with their stunning performing dance and percussion art service balinese hindu community who lives in europe could maintain steadfastness by respecting their own culture amidst the onslaught of a global culture he admitted that global influence penetrated all practical activities and influenced all aspects of life albeit the unevaded facts thousands of the balinese diaspora and the local citizens respectfully attended the religious movement

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introduction precision medicine a comprehensive approach to patient care that takes into consideration genetics and the social determinants of health when diagnosing and treating disease 12 is prevailing among the priority areas for research in canada and should be considered the standard for patient care worldwide 3 the sdoh include socioeconomic factors that affect health and wellbeing such as income education and employment 4 such factors are affected by societal systems of oppression and are intimately linked to an individuals position in society relative to the societal status quo as neither genetics nor the sdoh alone can indicate health status the two must be viewed as intrinsically and inextricably linked to one another and thus to an individuals overall health and wellbeing 5 by definition a precision health care approach should be both personalized to the patient and humanistic with a multitude of health factors that can influence and are influenced by the sdoh they should be considered by physicians when managing their patients health concerns however many sdoh and barriers to care issues continue to be overlooked by physicians 6 7 8 research has shown that as many as 80 of internet users seek health information online 910 social media platforms internetbased userdriven community platforms for communication and sharing usercreated content 11 have flourished as virtual communities where people exchange information and opinions and seek support and advice from peers 12 13 14 such platforms include blogs wikis social bookmarking social network sites status update services virtual world content and mediasharing sites 11 specifically health information seeking is among the most popular online activities with dietnutrition physical activity signs and symptoms treatment and public health interventions as some common examples 8 9 10 121315 social media has been studied in attempts to improve health outcomes with mixed results but it is not yet clear what aspects of successful interventions precipitated their success 16 likewise the reasons for failure of unsuccessful interventions which led to worsened health outcomes or increased health inequity are not clear thus social media has the potential to positively moderate patient health but how it can be used correctly to maximize benefit and minimize repercussions for patients remains to be seen in part related to the accepted importance of understanding patients voices and perspectives it has been implied that social media use should also be taken into consideration by physicians as a determinant of health 6 although health care practitioners remain the principal trusted authority for health information the sdoh of the patientincluding accessibility barriers such as geography cost and timeresult in patient preference for online searching over inperson consultations 12 due to its social connectedness social media is one of the preferred venues for obtaining health information and community support and peers have been shown to influence health behaviors more than almost anything else 14 there are questions as to the accuracy and unbiased nature of online health information especially that which is disseminated on usercreated content platforms such as social media 81718 further an individuals internet competency does not necessarily equate to their medical literacy however whether or not social media is a net positive or negative mediator of health as we will argue it undoubtedly affects individual health status in unique and substantial ways and thus cannot be ignored by physicians in this paper we examine the complex relationship between social media and the sdoh we propose that social medias effects on health should be considered as part of the standard of care moreover we argue that a paradigm shift in the physicianpatient relationship is warranted one where physicians acknowledge the impacts of the sdoh on informationseeking behavior recognize the positive and negative roles of social media as a mediator of health through the lens of the sdoh and use social media to catalyze positive changes in the standard of care we suggest that only by broadening our understanding of the intimate linkages between social media and the sdoh and incorporating it as part of patient care can the gap be bridged effectively to deliver a vision of precision medicine that is inherently and sufficiently personalized the impacts of the social determinants of health on informationseeking behavior the government of canada recognizes 12 determinants of health including but not limited to biology and genetic endowment childhood experiences physical environment and access to health services 4 not all determinants of health are sdoh rather the sdoh are those that focus on social and economic factors such as race income and social status education and literacy and employment and working conditions the world health organizations commission on the social determinants of health has defined sdoh as the conditions in which people are born grow live work and age 19 it is imperative to consider who has access to the internet when discussing the demographics of social media users as social media users are by definition a subset of internet users access to the internet in general a requisite for accessing social media is related to factors underlying the sdoh this relationship between internet access and the sdoh influences what information individuals are accessing and how they are accessing it 2021 this in turn affects their use of digital tools such as social media which encompasses a wide array of websites and applications nearly 60 of the global population have access to the internet 22 nevertheless a digital divide exists and although internet use increases every year this digital divide highlights disparities in access for underserved populations especially those in lowand middleincome countries 142223 age an sdoh is also a factor contributing to the differentiated use of social media older adults tend to search for health information online significantly less than younger age cohorts such as generation y because they lack prior internet experience and thus possess lower internet competency 8142425 in addition evidence indicates that education another recognized sdoh and specifically higher education correlates with an increased likelihood of searching for health information online as does identifying as female 2026 overall people of low socioeconomic status or from lmic older adults and less educated individuals face the most substantial barriers to accessing the internet in general and social media in particular unfortunately this is the same population who stand to benefit the most healthwise from having access to health information online 14 the apparent need for internet access in specific sdoh segments reinforces clearly the statement delivered by the united nations human rights council that access to the internet is a basic human right 27 social medias potential as a positive mediator of health accessibility barriers to inperson care are currently unacceptably high 142223 and methods of communication between physicians and patients remain strictly in traditional formats 7 despite enormous advancements in internet technology and virtual communication patients are still required to appear inperson at a physicians office to communicate with a physician and receive care to do so requires substantial privilege on the part of the patient such as having the time and resources to attend an appointment recently due to the covid19 pandemic there has been an acute increase in emphasis on providing more virtual care however this is still quite limited and temporary as there isnt a lot of readiness for using virtual health care 28 although methods of communication between physicians and patients are at the heart of healthcare 7 they are traditionally designed using practices that appear to lag substantially behind modern methods in part due to regulatory bodies regulations and practice guidelines 28 although patients tend to seek health information online for a number of reasons the majority state that they would prefer to obtain this information from health care practitioners but it is simply not within their means to do so due to an inability to access care as a result of economic social cultural or physical barriers 2329 social media is largely free easy to access from multiple geographical locations and considered by patients to be more convenient timely costeffective 8 in some cases receiving care in person may be impeded by stigma in that regard social media is reported by users as privacy protective and less embarrassing 8 as a venue for seeking health information such perceptions are not always accurate as will be discussed in the following section and they by no means represent all social media users 30 further social media is inclusive provides a sense of solidarity hence enhancing the attribute of community support and grants a greater perceived sense of control to patients over their own health 29 patients have reported that information received from physicians during inperson consultations was not clear satisfactory or conductive for asking additional questions 31 this may be one of the reasons that patients turn to social media for health information when this occurs they report feeling more knowledgeable confident and empowered in their abilities to communicate with health care practitioners 6 patient satisfaction is thus improved when social media is used as a tool for obtaining health information perhaps equally important to decreasing accessibility barriers and increasing patient access to health information social media also acts as a support network 1213 one study found that support networks are a preferred venue for obtaining health information second only to physicians 12 support networks including those facilitated by social media are linked to the sdoh 32 33 34 and substantially affect health behaviors 35 this is useful for health promotion and health outcomes as people may be persuaded to partake in positive health activities such as healthy diet exercising 36 37 38 and receiving their annual flu shot if their peers have posted publicly about participating in these activities 39 in sum social media has the ability to mitigate the sdoh that result in limited physical accessibility enhance personal confidence and empower patients communication with their physicians social medias potential as a negative mediator of health for all the aforementioned benefits social media is not exclusively a positive mediator of health 2940 there are notable problems with obtaining health information on social media direct implications of social media use on health and a problematic homogeneous single story narrative that is presented it is important to acknowledge the negative and potentially dangerous effects of social media on health to reconcile them social media tends to present information of questionable credibility and it is oftentimes sponsored by a potentially biased entity 8 occasionally online health information is entirely false 17 in addition although it may provide patients with a sense of privacy in comparison to discussing stigmatized topics in person with physicians there are notable concerns about anonymity and privacy when obtaining health information online 29 confirmation bias is another welldocumented danger associated with seeking health information online 18 personalization algorithms on social media platforms can further polarize the information available to patients though recommended or suggested content 1341 this content is automatically sourced based on previous social media activity and it is presented to the user whether they are seeking it or not antivaccination content is a particularly good example as parents who search for vaccine information online are more likely to hold antivaccination beliefs and possibly be active on similar communities of interest 1018 emerging literature is increasingly documenting the direct impacts of social media on health 1335 social media has been found to promote a sedentary lifestyle increase selfisolation decrease quantity and quality of sleep and negatively impact mental health 13 social contagion a recently documented phenomenon depicts the contagious nature of certain noncommunicable health conditions over social media including obesity and emotions such as happiness anxiety and depression 35 social influence and peer recommendations may substantially alter a persons health behaviors as well likely due to susceptibility to peer pressure desire to belong to a group or feel supported and perception of credibility of the recommendations 143542 a vicious cycle between anxiety and online health information seeking is another documented phenomenon where high levels of anxiety are associated with xsl • fo renderx online health information seeking the findings of which further increases anxiety 43 in 2009 chimamanda ngozi adichie delivered a now renowned tedtalk about the dangers of a single story narrative single stories emerge when only one narrative about a group of people is widely shared and accepted it then becomes assumed that all members of said group shared the same experience one that aligns with the single story recently this concept was extended to stories of health experiences shared on social media 40 an anthropological study found that single stories of health experiences are disseminated widely across social media platforms not only do these single stories ignore variation in individual experiences and personal sdoh but they also tend to hold little truth at all any deviation from the single story on social media including any disclosure of personal experiences is discredited and rejected dehumanizing those who do so physicians must be made aware of the homogeneity of information on social media and how this may affect their patients perceptions of health and health experiences further patients using social media as an online community wherein they may communicate with others with similar health conditions must be empowered to tell their own story while acknowledging that it may not align with the stories of others subjective recounts of disease are not necessarily misinforming so long as patients understand the difference between individual perception and experience of disease versus etiology and treatment of disease the latter of which necessitates a degree of prerequisite medical knowledge that goes above and beyond digital literacy 4445 using social media to catalyze positive changes in the physicianpatient relationship although the positive role of social media as a mediator of health is ample it is also imperative to address and mitigate the negative aspects of social media such as security and privacy concerns work must be done on the part of the physician and the patient to shift the physicianpatient relationship toward one that is inclusive of the role that social media plays in health and that uses social media as a tool to promote health and wellbeing during inperson consultations physicians must be open to discussing the roles of social media as a mediator of health in a recent interview patients perceived health care workers to be in overt or tacit opposition 6 to any mention by patients of health information retrieved online such mentality reflects the traditional physicianpatient relationship where patients hold little autonomy over their own medical journey 23 take for example a scenario wherein a patient cindy a 24yearold veterinary technician discloses to her physician concerns around the covid19 vaccines cindy is a firstgeneration immigrant living in a multigenerational home and is worried that she may become contagious with the virus immediately after immunization posing a health risk to her older adult immunocompromised grandmother if her grandmother were to fall ill cindy fears that her family would not be able to afford the necessary care therefore cindy feels it is best for her family not to get the vaccine for the physician to mitigate these concerns it is imperative that they attempt to discern from where these anxieties originate to write off cindys beliefs simply because they are biomedically unfounded and derived from information sought on social media could be counterproductive in protecting or improving her health further social media may be used as an indirect line of communication between physicians and patients if used as a venue for health knowledge dissemination and translation for the purpose of health promotion 4647 to elaborate physicians or health care experts may communicate with their patients on social media via public posts about healthpromoting behaviors they recommend and providing them with trusted links for further information in addition physicians may refer their patients to patientdriven online advocacy groups such as the light collective a nonprofit organization that among other objectives works to shine a light on privacy breaches and socalled bad datasharing 30 this would aid in decreasing misinformation and diversifying the pervasive singlestory narratives that encapsulate many health conditions we recognize that it is not only up to the physician to identify and quell misinformation on social media it is largely up to the platform itself to create regulatory policies and practicesor better yet algorithms to identify problematic posts 48 to minimize false or misleading content and to ensure that it is not being amplified in recommended or suggested content in the previously discussed scenario it is possible that cindy would not have developed such concerns over the covid19 vaccines had she viewed credible biomedical data or conversely had she not viewed biomedically unfounded data on social media this is especially likely if cindy is passively consuming data a patients level of education and literacy as an sdoh impacts their level of medical literacy 49 which is only as good as the information they have acquired it may be rendered obsolete if the knowledge they have gained is inaccurate therefore patients should feel empowered to ask questions during their inperson consult or through anonymous or confidential online forums wherein knowledgeable health care practitioners provide answers although it is important for physicians to provide health care information to patients in terms that they are able to understand we posit that it may also be beneficial to provide patients with a list of the formal medical terms associated with their condition this may improve the caliber of search results they find online and reduce the likelihood of conflating different conditions or symptoms based on the colloquial descriptions given to them by their health care provider finally patients should be encouraged to approach social media platforms in the context of health with curiosity and skepticism embracing the community and solidarity aspects they may provide to those facing similar health problems while ensuring that objective medical data are not trusted until substantiated by scholarly sources or health care practitioners for cindy a list of search terms will allow her to return home and actively seek reputable information on the covid19 vaccines on the contrary a lack of takehome information may result in cindy searching what she knowscontagious after covid19 vaccinewhich may elicit misguiding results that confirm her bias a brief but thorough discussion with her physician about the dangers of passively consuming bad data on social media may also prevent such encounters in the future summary in this paper we reviewed the complex multifaceted and dynamic intersections of social media and sdoh in the era of precision medicine we argued for its inclusion as part of routine patient care and demonstrated the potential of social media to be used as a positive mediator of health so long as its negative mediation effects are minimized further we discussed how the physicianpatient relationship must shift to accommodate for the everincreasing role of social media in health and best use social media as a tool to improve health outcomes these intricacies warrant further research however to conceptualize our study into a framework of understanding and development in this area we present figure 1 that we believe captures the potential challenges and areas of contention in bringing social media into precision medicine 1 the benefits of social media use in health care are listed in the first ring surrounding social media social media can act as a support network promoting informationseeking behaviors allowing patients to determine their own appropriate care and enabling health information access all affected by and affecting the sdoh 2 however social media also brings challenges to promoting health as is illustrated in the second ring although privacy and access to social media are common issues the public also faces the issue of veracity of information further patients face an information homogeneity problem in the form of social medias single story which does not account for diversity of experiences embodied by the sdoh 3 physicians and patients have different perceptions of how social media may be used in relation to health care largely due to miscommunication although the public expects to receive personalized health care physicians deliver their version of this as precision medicine in addition although the public perceives societal issues as equity diversity and inclusion challenges physicians understand these issues as they relate to health and categorize them as the sdoh this is not an issue of incongruity but one of language communication barriers must be acknowledged to be overcome 4 future research in this domain needs to recognize the complex dynamics of how social media interacts with the sdoh to develop solutions that can comprehensively improve the delivery of health care in the future conclusion as the role of social media in health evolves new directions of research are needed to better understand the impacts of social media on health and inform physicians on how it can be integrated as part of patient care our discussion posits that health and social media are intimately linked through the prism of the sdoh and that this linkage is only amplifying over time we argue that it is thus ineffective and even counterproductive for physicians to ignore this relationship and the impact it has on designing the medical encounter and the delivery of care for physicians to deliver the highest standard of care under the definition of precision medicine the complex interaction between social media and the sdoh and their impact on one another must be taken into consideration authors contributions emef drafted and critically reviewed the manuscript hl bc es ajg and hg conceived the project and critically reviewed the manuscript conflicts of interest none declared abbreviations lmic lowand middleincome countries

as many as 80 of internet users seek health information online the social determinants of health sdoh are intimately related to who has access to the internet and health care as a whole those who face more barriers to care are more likely to benefit from accessing health information online assuming the information they are retrieving is accurate virtual communities on social media platforms are beginning to serve as venues for seeking health information online because peers have been shown to influence health behavior more than almost anything else as a positive mediator of health social media can be used as a direct or indirect mode of communication between physicians and patients a venue for health promotion and health information and a community support network however false or misleading content social contagion confirmation bias and security and privacy concerns must be mitigated to realize the full potential of social media as a positive mediator of health this paper presents the shifting dynamics of how such communities are affecting physicianpatient relationships with the intersections between the sdoh social media and health evolving physicians must take into consideration these factors when establishing their relationships with patients we argue a paradigm shift in the physicianpatient relationship is warranted one where physicians acknowledge the impacts of the sdoh on informationseeking behavior recognize the positive and negative roles of social media as a mediator of health through the lens of the sdoh and use social media to catalyze positive changes in the physicianpatient relationship we discuss how the physicianpatient relationship must evolve to accommodate for the everincreasing role of social media in health and to best use social media as a tool to improve health outcomes finally we present a fluid and multicomponent diagram that we believe will assist in framing future research in this area we conclude that it is ineffective and even counterproductive for physicians to ignore the relationship between social media the sdoh and health their impact on one another and the effect it has on designing the medical encounter and the delivery of care under the definition of precision medicine

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2050 1 with the rise in the share of the aging population new concerns emerge such as increased demand for healthcare facilities rising medical costs and a decreasing labour force 2 to address this in near future it is important to understand the current status of the aged population in a country which is uniquely different due to its sheer size of the population the term successful aging was coined in the 1950s and gained popularity in the 1980s 3 the main characteristics of successful aging are freedom from disease and disability good cognitive and physical functioning and social and constructive participation 34 although the operationalization was not strictly followed several studies in developed and developing countries were conducted using the definition of rowe and kahn 5 it was reported that the their definition includes several dimensions of simultaneously assessed health outcomes such as physical cognitive and social functioning as well as the disease status and thus a greater input is needed in defining successful aging 6 studies on successful aging in asia have focused on specific components or added new components including nutritional status in rowe and kahns model and used modified versions 7 8 9 such modifications in asian studies have limited the comparison of successful aging with developed countries however may benefit in understanding the degree to which the opportunities of successful aging vary across different subgroups of older population in asian settings considering health as a major component of successful aging there are gender variations that can be seen in disability and disease prevalence degree of physical and mental functioning and health expectancy and mortality 10 11 12 women on average outlive men however women are more likely than men to rate themselves lower on the physical and psychosocial resources metrics that are frequently used to assess wellbeing in old age 1314 having a social life in the form of a sense of belonging solid social links and social support is another critical component of aging successfully the disparity in life expectancy between men and women and womens proclivity to marry older men has resulted in a global situation where more older men are married while more senior women are widowed and living alone with more significant disadvantages 15 this trend of older women living alone is most visible in western countries but it is also becoming a norm in developing countries due to young peoples migration to metropolitan areas for jobs leaving their parents behind 1617 successful aging is considered a viable solution to the burdens placed on healthcare systems and financial and social security in societies with aging population 18 therefore the present study aims to determine the prevalence of successful aging and explore the factors contributing to gender differentials in successful aging among older adults in india the study hypothesized significant gender differentials in successful aging among older adults aged 60 years and above in india material and methods data this study utilizes data from indias first nationally representative longitudinal ageing survey in india 201718 which investigates the health economics and social determinants and consequences of population aging in india 19 the representative sample included 72250 adults aged 45 and above and their spouses across all states and union territories of india except sikkim the central ethics committee on human research under the indian council of medical research extended the necessary guidance guidelines and ethics approval for conducting the lasi survey the lasi adopted a multistage stratified area probability cluster sampling design to select the eventual observation units households with at least one member aged 45 and above were taken as the eventual observation unit the study provides scientific evidence on demographics household economic status chronic health conditions symptombased health conditions functional and mental health biomarkers health care utilization work and employment it enables the crossstate analyses and crossnational analyses of aging health economic status and social behaviours and has been designed to evaluate the effect of changing policies and behavioural outcomes in india detailed information on the sampling frame is available in the lasi wave1 report the present study is based on a sample of 31464 older adults defined as those aged 60 years and above 19 outcome variable the outcome variable successful aging was dichotomised and was coded as 0 no and 1 yes 20 successful aging differs from region to region and the present paper defined successful aging based on the composite index created by rowe and kahn 2021 the six components were 1 absence of chronic diseases 2 free from disability 3 high cognitive ability 4 free from depressive symptoms 5 active social engagement in life and 6 free from obesity the older adults satisfying all the above conditions were considered the successful aging group 20 the six components are as follows 1 absence of chronic diseases chronic diseases were assessed from the question have you been diagnosed with conditions listed below by a doctor the illnesses were hypertension chronic heart diseases stroke any chronic lung disease diabetes cancer or malignant tumour any bonejoint disease any neurologicalpsychiatric disease or high cholesterol 22 respondents were classified as having no chronic diseases if they reported having none of those mentioned above conditions 2 free from disability activities of daily living is a term used to refer to normal daily selfcare activities the ability or inability to perform adls is used to measure a persons functional status especially in the case of people with disabilities and older adults 2324 respondents were classified as having no disability if they were adl independent 25 3 high cognitive ability cognitive impairment was measured through five broad domains memory was measured using immediate word recall delayed word recall orientation was measured using time and place measure arithmetic function was measured through backward counting serial seven and computation method executive function was measured through paper folding and pentagon drawing method and object naming was lastly done to measure the cognitive impairment among older adults a composite score of 043 was computed using the domain wise measure the lowest 10th percentile is used as a proxy measure of poor cognitive functioning 19 the older adults who did not fall into the category of lowest 10th percentile were considered as having high cognitive ability 26 4 free from depressive symptoms the probable major depression among the older adults with symptoms of dysphoria calculated using the cidisf score of 3 or more on the scale of 010 this scale estimates a probable psychiatric diagnosis of major depression and has been validated in field settings and widely used in populationbased health surveys 1927 the score of more than three was categorized as depressed and viceversa the respondents with a body mass index of 30 and above were categorized as obese 28 explanatory variables main group variable gender was coded as male and female and was considered as the main group variable in the current analysis individual factors age was coded as young old oldold and oldestold education was coded as no education primary schooling not completed primary completed secondary completed and higher and above marital status was coded as currently married widowed and others 22 work status was coded as working never workedretired and currently not working living arrangement was coded as living alone living with a spouse living with children and living with others tobacco and alcohol consumption was coded as no and yes 22 physical activity of respondents was assessed based on the question how often do you take part in sports or vigorous activities such as running or jogging swimming going to a health centre or gym cycling or digging with a spade or shovel heavy lifting chopping farm work fast bicycling cycling with loads physical activity status was coded as frequent rare and never 22 household factors the monthly per capita expenditure quintile was assessed using household consumption data sets of 11 and 29 questions on food and nonfood items expenses respectively were used to canvas the sample households food expenditure was collected based on a reference period of seven days and the nonfood cost was compiled based on reference periods of 30 days and 365 days food and nonfood expenditures have been standardized to the 30day reference period the mpce is computed and used as the summary measure of consumption the variable was divided into five quintiles ie from poorest to richest 19 religion was coded as hindu muslim christian and others caste was recoded as scheduled tribe scheduled caste other backward class and others caste is a form of social stratification based on the societal position of population groups and is specific to india the sc and st group are among indias most disadvantaged socioeconomic groups and historically belonged to the lowest rung of the now constitutionally abolished indian caste system the st group consists of a predominantly tribal population the obc is the group of people who were identified as educationally economically and socially backwards with conditions better than the stsc population the other caste category comprises none of the st sc and obc groups the place of residence was coded as rural and urban the region was coded as north central east northeast west and south statistical approach descriptive analysis along with bivariate analysis was carried out to present the preliminary results a proportion test was used to evaluate the gender differentials and find the significance level 29 further binary logistic regression analysis 30 was used to determine the factors for successful aging among older adults the results were presented in an adjusted odds ratio with 95 confidence interval in this study the odds ratio of greater than 1 for a given category of the independent variable denotes higher odds of successful aging given the effect of all other independent variables remain constant a multivariate decomposition analysis 31 was used to identify covariates contributions explaining the group differences in average predictions the decomposition analysis aimed to identify covariates that contributed to the change in successful aging by gender of older adults the multivariate decomposition analysis has two contribution effects compositional differences and the effects of characteristics that differ in the coefficients or behavioural change of responses for the selected predictor variables 32 the svyset command was used in stata which controls the analysis for complex survey design and also weights are adjusted making the results nationally representative results univariate distribution table 1 shows the individual and household characteristics of 15098 male and 16366 female older adults in india the mean age for male and female respondents was 693 years and 691 years respectively we observed that nearly 60 of older adults of either gender were in the youngold age group further one in ten one in two and one in four older men had higher education never workedretired and were living with spouses respectively a total of 82 of older women had no formal education 81 either never workedretired or were currently not working and 15 were living with their spouses while 60 of males never engaged in physical activity the same was higher in older women additionally 26 of older adults belonged to the scst caste and almost 70 lived in a rural residence estimates from bivariate analysis table 1 gives the bivariate distribution of male and female older adults with successful aging by selected explanatory variables we observed significant gender differences in successful aging by the individual household and community characteristics there was significant gender differential in successful aging a higher proportion of older men had experienced successful aging across all age groups than their women counterparts moreover among older adults with successful aging a higher proportion of males had no formal schooling were working were living alone and had frequent physical activity in comparison to their female counterparts coming to the poorest quintile household we observed that 38 of older men experienced successful aging compared to 29 among women similarly 37 and 27 of older men and women living in rural areas experienced successful aging moreover these differences by gender were statistically significant at the 1 level logistic regression estimates of successful aging table 2 presents the logistic regression estimates for successful aging among older adults in india as mentioned earlier the odds ratio of greater than 1 for a given category of the independent variable denotes higher odds of successful aging given the effect of all other independent variables remain constant we found that older women had lower odds aor 087 ci 081 094 of successful aging than older men in the study moreover youngold adults had higher odds of successful aging compared to oldestold adults aor 173 ci 157 191 working older adults had higher odds of successful aging than older adults who were not working aor 166 ci 153 181 older adults who were currently married had higher odds of successful aging than widowed older adults aor 121 ci 113 130 older adults living with their children and spouse had significantly higher odds of successful aging than older adults living with others aor 120 ci 105 137 older adults who did not consume alcohol had significantly higher odds of successful aging than older adults who consumed alcohol aor 109 ci 101 117 also older adults in urban areas had lower odds of successful aging aor 092 ci 087 098 than their rural counterparts older adults belonging to the richest quintile of household wealth status had lower odds of successful aging in this study aor 069 ci 063 075 than their poorest counterparts table 3 provides the logistic regression estimates of each component of successful aging with mpce quintile among older adults in india stratified by gender older adults who belonged to richest quintile were disadvantageous in terms of the components of absence of chronic diseases among males aor 049 ci 044 055 and females aor 051 ci 045 057 free from depressive symptoms among males aor 064 ci 051 081 and free from obesity among females aor 050 ci 040 062 compared to the poorer group those in the rich category had significantly increased odds in case of high cognitive ability and active social engagements than their poor counterparts decomposition of gender differences in successful aging table 4 shows the contribution of individual and household characteristics to gender inequality in successful aging among older adults the results show significant gender inequality in successful aging further 88 of the gender difference can be explained by the differences in distributions of characteristics considering the differences due to characteristics we observed that most of the gender gap in successful aging would be reduced if women had similar status as currently working as their male counterparts moreover bringing the level of frequent physical activity in women to the same levels observed in men would reduce the gender gap by 9 at the aggregatelevel we found that 35 of gender difference in successful aging is attributable to difference in the distribution of individual among older women and men considering the differences due to coefficients a significant gender gap would have reduced if the similar proportion of older women had at least primary level of education as men also if older men had an equal chance of living in a rural community as their female counterparts it would facilitate a 22 decrease in the gender gap in successful aging discussion this article aimed to explore the frequencies and gender differences in successful aging in older men and women in india and the factors contributing to those differences using the definition of rowe and kahn the study identified 343 of older men and 256 of older women as successfully aging multiple studies have used and operationalized various definitions including a few with a single component of the absence of diseases and found the frequency of successful aging ranging from 1 to 90 of the participants 33 therefore comparing the current finding with the existing studies is difficult using a similar model of successful aging a recent multicountry study in china korea and japan found that 176 of the population aged between 65 and 75 were successful agers 34 similarly a survey among chilean older adults using a multidimensional 20item successful aging inventory devised by troutman 35 identified more than 64 of the participants as aging successfully 36 importantly our data showed significant gender differences with older men having higher odds of successful aging than women this finding was consistent with previous studies suggesting that women have higher morbidity than men due to acute and chronic physical and psychological disorders and even when variables related to reproduction were dropped the variations in morbidity remained 37 38 39 40 also the assessment of functional health including measures of difficulty in executing functions related to adl such as eating getting dressed washing and using the bathroom demonstrated significant disparities in favour of men 4142 similarly previous studies show that physical restrictions such as adl affect older women more than men 4344 again better cognitive functioning among men than women could be the basis of many other healthier personal choices allowing men to age more successfully than their female counterparts 45 46 47 additionally due to higher widowhood rates social isolation and loneliness among older women are considered the most concerning issue in successful aging studies 48 49 50 51 several explanations have been documented on the gender variations in morbidity for example men are more likely to suffer from diseases such as cancer hypertension and heart disease 52 53 54 women on the other hand have higher rates of chronic conditions such as arthritis osteoporosis related fractures and depression these disorders harm mental and physical health but have a lower risk of death than cancer hypertension and heart disease 39 55 56 57 on the other hand women have a higher incidence and prevalence of dementia than males partly owing to womens longer life expectancy and the increasing risk of different diseases as they age 5859 another common reason for the gender variation in morbidity is that men and women have different lifestyles strongly linked to mortality and have been more widespread in men for years 60 in parallel with this the present study found that physical activity contributed majorly to the differentials in experiencing successful aging this could partially be explained by the possible reverse causality that successful agers may have greater physical reserves to undertake physical activity although causal connection is not established older men and women should increase physical activity appropriately by participating in householdrelated activities physical exercises and voluntary activities as physical activity could help preserve health and practical functionality in older people and reduce the risk of chronic diseases 61 while smoking and drinking are regarded as dangers that primarily influence mens morbidity and death the presently evident obesity pandemic is more prevalent among women and poses a particular challenge to their health and functioning 62 hence interventions that address the adverse dietary patterns and malnutrition among older people should be developed through a gender lens in addition men might have variables related to healthier lifestyles and better qualitative aspects of social interactions during their earlier lives giving them a higher chance of aging successfully than women as evident in past studies social disadvantage experienced by women in the form of increased responsibilities for housework lower education and low socioeconomic status led to worse access to healthcare and higher morbidity 41 42 43 in support of this our findings suggest that marital status and living arrangements significantly contribute to the sex differences in successful aging interestingly the current results showed an advantage for economically poor and ruraldwelling older adults in successful aging which is in variance with an extant study showing a lower score of successful aging among socioeconomically poor people and rural residents 63 this finding could be attributed to the increased likelihood of underdiagnosis and underreporting of diseases among lower socioeconomic groups in india as suggested by multiple studies 64 65 66 a recent study indicates that more than half of indias urbanrural gradient in disability is attributable to education and household wealth distribution compared with less than 20 in china 67 hence the successful aging disparity can partially be explained by the differential poverty and illiteracy rates in urban and rural areas also as evidence suggests older people with higher socioeconomic status and those who reside in urban areas are more likely to have several lifestyle diseases including obesity 226869 which may ultimately result in poor mental and physical performance and lower rate of successful aging one of the studys limitations is that we cannot make any causal inferences about gender differences in experiencing different rates of successful aging for older people in india due to the crosssectional design secondly the definition of successful aging can raise special attention because it is highly multidimensional and heterogeneous 33 we used the definition according to the existing literature classifying a few individuals as aging successfully which can probably affect reducing or increasing the number of associated variables that are particular in the specific sociocultural context conclusion this study adds to the literature on the interplay between gender and experiencing successful aging we found that women consistently had a lower score in successful aging which is attributed to several socioeconomic and behavioural factors including education household consumption quintile and work status the findings suggest that within the changing sociodemographic and epidemiological landscape of indian society it is essential that public health initiatives be developed with a gender perspective to promote social and mental wellbeing and prevent physical and functional disability considering that women appear to face more significant disadvantages than men more studies must be conducted to explore the reasons for such differences and what factors in lowincome countries create differences among older men and women in achieving successful aging the future studies should also investigate the counterintuitive finding related to the lower rate of successful aging among people belonging to urban regions and the rich consumption quintile competing interests the authors declare no competing interests competing interest the authors declare that there is no competing interest • 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 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background rowe and kahn define successful aging as a high physical psychological and social functioning in old age without major diseases it is considered a viable solution to the burdens placed on healthcare systems and financial and social security in societies with aging population the present study aimed to determine the prevalence of successful aging and explore the factors contributing to gender differentials in successful aging among older adults in indiathis study utilized data from the nationally representative longitudinal ageing study in india conducted in 201718 the study is based on a sample of 15098 older men and 16366 older women aged 60 years and above the outcome variable was a dichotomous measure of successful aging with six components including absence of chronic diseases free from disability high cognitive ability free from depressive symptoms active social engagement in life and free from obesity older adults satisfying all these conditions were considered aging successfully descriptive and bivariate analyses were carried out proportion test was used to evaluate the gender differentials and reflect the statistical significance in the associated factors multivariate decomposition analysis was conducted to identify covariates contribution in explaining the gender differences in successful agingthere was a significant gender difference in successful aging among older adults in india difference 87 pvalue 0001 with 343 older men and 256 older women experiencing successful aging a proportion of 88 of gender difference in successful aging was explained by the differences in the distribution of characteristics coef 0082 pvalue 005 considerable gender gap in successful aging would be reduced if women had similar levels of work status 28 reduction to their male counterparts bringing the level of frequent physical activity in women to the same levels observed in men would reduce the gender gap by 9 the findings suggest that women had a lower score in successful aging which is attributed to several socioeconomic and behavioural factors including not working status and physical inactivity more studies must be done to explore the reasons for such differences and what particular factors in lowincome countries create differences among older men and women in achieving successful agingthe global population aged 65 and above is predicted to rise from 9 in 2020 to 16 by 2025 1 india also faces a rapid population aging with a predicted 13 rise in the population aged 60 years and above between 2005 and

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introduction in recent years there has been a growing international urgency to include disabled persons on university campuses ideally this inclusion runs deeper than a mere increase of disabled students on tertiary grounds it also involves the quality of the social and learning experiences of disabled students once they have gained access to higher education in essence real inclusion therefore means feeling like a welcomed member of the tertiary environment a member that truly belongs and whose contributions to the diversity of the university are valued and celebrated what has been missing from previous research on disabled students is an embodied account of their lived experiences so far we have heard their accounts of the learning and social environment but we have not heard how they experience the tertiary environment viscerally in their flesh and bones it is partly and crucially through the lens of their lived realities that the ability of universities to implement inclusive policies will be illuminated what is more a phenomenological account where bodily experiences of disability are recognised and documented may point us in the direction that is needed for change as overboe writes our lived experience would be an integral part of the atmosphere and tone for any change within our lives and our interaction with others whether they be disabled or nondisabled with this paper we therefore intend to look at the daytoday experiences of visually impaired students through their embodied recollections disability and the body the recognition of bodies and personal lived experience are contentious issues within disability circles although the body was never quite absent from disability theory the social and medical models cast it into the marginal shadows of meaningless biology on the one hand the medical model which has been the predominant way of thinking about disability until the late 1970s simply depicted the disabled body as a passive voiceless entity as a body gone wrong it defined disability as a tragic infliction that rests solely on biological deficits on the other hand early social model writers who believe that disability primarily stems from societal barriers severed the disabled body from its biological roots through its impairmentdisability separation in this sense impairment refers to the physical or medical basis of a disability that encapsulates the limitations of physical sensory or psychological function while the term disability was used to describe the social exclusion and barriers imposed on people with disabilities in essence this distinction also left the impaired body as nothing but its physiology in both accounts the body was therefore devoid of meaning history culture or agency nothing but a corporeal mass recently authors started arguing for a different understanding of the disabled body this new understanding of the body moves away from the purely biologically created entity to a body that is changing over time that has personal and emotional facets that is culturally created and influenced and that is the host of deeply meaningful experiences in response some social model writers warned that a focus on the personal lives and troubles of disabled persons may have a damaging effect on the collective lives of people with disabilities as it steers attention away from wider social structures that lead to exclusion and shun impaired bodies to the margins of society it is evident that these authors are deeply concerned that the gaze of disability scholars will turn inward leaving the social models political and social progress null and void of course given the history of medicalisation and marginalisation their caution that embodiment will leave the impaired body once again disempowered is not completely ungrounded and maybe even somewhat plausible however there also lies a personal danger in denying the reality of the body with its joys pain laughter and tears connolly citing merleauponty points out that it is our subjective bodily experiences that connect us to the world and make it meaningful and real for winnicott this unity of body and psyche is a fortunate achievement he writes how easy it is to take for granted the lodgement of the psyche in the body and to forget that this again is an achievement it is an achievement which by no means falls to the lot of all in dislodging the impaired body from disabled social reality we face the risk of dissociating people from their very real emotional struggles in a collective push to deny these experiences and this dissociation in its reduction of the body to a purely objective entity threatens to leave the world we live in empty and devoid of all meaning fortunately an investigation into bodily experience does not have to provide a purely medicalised perspective paterson and hughes argue that phenomenology can expose oppressive societal structures while simultaneously capturing lived experience this possibility is fleshed out in the illnessand disabilityrelated formulations by rosemarie garlandthomson and havi carel these authors sensitively attempt to explain the relationship and interactions between a body that is disabled and a world that is not these interactions do not happen seamlessly since the contours of disabled bodies often do not fit snugly within the shape of the world garlandthomson refers to this incongruency between flesh and the world as misfits she goes on to explain that disabled bodies fluctuate between fitting and misfitting in conjuncture with a welcoming or rejecting world ramps for wheelchairs for example signify a welcoming environment an environment that allows for fit with a body that is mobility impaired yet despite efforts to aline the world with disabled bodies physical environments and social encounters still largely fail to create a fitting space for them although havi carel does not directly refer to the concept of misfits her phenomenological formulation of illness also address the somewhat awkward relationship between a disabled or ill body and its surroundings her writings about nondisabled possibilities and limiting bodies elegantly shows the rift between a body that fits the world and one that does not typically she explains we have the option of choosing between a range of possibilities accepting some and rejecting others when walking past a library for example i may choose to enter or walk past it if i decide to enter i have the choice of searching for a book going directly to the librarian working on the computer and so on if i choose searching for a book on my own i can go to the shelf search for the book and start reading through it now i am presented with the option of taking it out or putting it back on the shelf however when i cannot see when i am blind my horizon of possibilities shrinks walking past the library i may not even be aware of the existence of the library thus leaving me with no option of entering it however let us say i am deliberately walking to the library upon entering the library i may not be able to search for the book directly since i would be unable to see and find the book if the computer does not have a screen reader this option might also be closed to me so i will have to ask the librarian or someone else for assistance in finding the book when finally i have the book i cannot simply open the book and read it i will have to take it out ask someone to scan it into an accessible format for me read through it and then decide whether i want it or not in this example we can see how not only possibilities are limited but time is also altered it therefore comes as no surprise that hass argues that a limited horizon of options changes ones entire existence in other words being unable to see does not mean only the loss of physical sight but also entails a narrowing of possibilities that changes ones beingintheworld carel goes even further by stating that disability like somatic illness shrinks the innate possibilities of typically useful objects a practical tool like a pen loses its usefulness as a readytohandentity and morphs into a presentathand entity which confronts us with its empty meaning and uselessness for example the typical purpose of a pen is writing however in my sightlessness i have no mainstream use for it i cannot write with it i cannot see what someone else wrote with it in my hands it becomes a useless object without meaning of course i can retain some meaning by using the pen as a hairpin but in this the main purpose of the pen in its everyday usage is lost once again ones entire beingintheworld is altered for the loss of meaning does not pertain to a single object it changes ones entire interaction with objects in the environment it is not just that book that library or that pen that become useless and unattainable but the entire environment becomes hostile and uninviting these theoretical formulations of disabled bodies within the world clearly allow the space for accounts of hurt and suffering while removing these narratives from charitable discourse by illuminating oppressive practises suffering now becomes balanced between pain and oppression and it helps one think more clearly about disability becoming embodied as suffering we remain aware of our own feelings of pain and yes personal tragedy while remaining ever mindful of how the bodily experiences are drenched with oppression and societal structures that may exclude us it thus remains a balancing act knowing that societal structures are embodied and the body becomes social tying all loose ends together paterson and hughes remark the disadvantaged corporeal status of impaired bodies cannot be understood without the wider material and social position of disabled people but neither can it be divorced from the painful intimacies of the lebenswelt we would argue that through listening to the embodied experiences of visually impaired students important roleplayers like policy planners will begin to understand what is needed for a true inclusive environment for all narratives of the daytoday lives of these students will not only tell of their personal lives but will also unveil practices that might keep them at the periphery of higher educational terrains methodology since phenomenology is concerned with the sensitive task of examining the qualitatively rich phenomena of human experience this study explored the daytoday lives of 15 visually impaired students in the search for a meaningful account of their lifeworlds all students attended a south african university at the time of the research individual and focus group interviews were conducted with openended questions in order to delve deeper we nto the meaningful amalgamation of their emotions thoughts and bodily experiences we analysed the interviews according to the principles of interpretative phenomenological analysis because it leaves room for accounts of lived experience this meant that we analysed the interviews of each participant individually in order that the findings would reflect the detailed deep layers of their experiences in other words the idea was to discover and reveal the heart of the lifeworlds as experienced by the individuals who are living it after the individual case analysis we looked for patterns across the analysed cases this involved the grouping of similarities and differences across the cases restructuring and relabelling the original individual themes so that patterns of meaning became clear in a final account of their shared experience results the narratives of the students addressed three themes that centred around their embodied experiences within the tertiary environment these were disabled bodies and the physical environment the embodied experience of reading and shameful and confusing bodies and the social world disabled bodies and the physical environment the students experienced the wideopen spaces of an unfamiliar university campus as foreign and not designed with their bodies in mind some students made an attempt to prepare themselves for the physical challenges of walking alone they visited the campus beforehand and paid for an orientation and mobility instructor to teach them the routes to class even though these preparations were somewhat helpful it did not prepare them sufficiently for the daytoday challenges of walking the campus for example mia recalled that even though she knew the way to class beforehand she was not prepared for the lastminute changes to class venues and in the end we didnt have classes in most of those classrooms because everything was changed and then i sort of had to teach myself the way all over again and it was difficult for me because i didnt know exactly where my classes were and then they write on the board classes are there and there and then during the first class they decide we are not here anymore now we are going to be in that class on that floor and it was difficult and i felt uncertain because i couldnt memorise where all my classes were because the passages was so confusing for sue visiting the university beforehand did not prepare her for walking amongst large crowds i came here to see what it looked like not on an open day but just on a usual day but still it isnt the same like being surrounded by thousands of students its kind of a different experience mia recalled that she initially avoided going back to the hostel for lunch for fear of walking independently amongst hundreds of students it was terribly difficult for me to … later i simply didnt go to the residence for lunch because you know it was terribly difficult with my cane … i didnt know my way properly then i had to try and find my way back to the residence amongst countless students simply getting around campus was therefore a very challenging task for the students disturbingly some of the students also found the physical environment to be potentially dangerous for example they spoke about the threat of motor vehicles and obstructions in the environment the other day i was at a pedestrian crossing then i saw a car that seemed rather far away but he clearly drove fast and he just came he didnt stop he was i think if he drove a centimetre further he wouldve driven over my foot obstructions in the environment included holes in sidewalks lowhanging branches and road works i hate it when i walk on the sidewalks and a branch hits me through the face and i think people dont consider things like this when they trim the trees … or i fall in uhm potholes in the road it is therefore no surprise that the students especially initially experienced strong emotions when thinking about or facing walking independently these students felt uncertain scared and extremely worried they often experienced these emotions when even just anticipating walking alone in the morning some students had to gather themselves and find enough courage before walking to class it takes a bit of my energy to find my way to places each time its like okay okay i pluck up the courage here i go uhm so i so i get by but each time its a bit of an emotional experience it sounds very very lame and probably childish but for the first two weeks of my academic year it was my greatest concern not how i would manage in class but how i am going to get where i want to be and how am i going to find my way between classes you have this worry you have this fear how on earth am i going to get to the willcocks when you get there its like okay im here its over now we start worrying how we are going to get back theres always a worry when they were not worrying about finding their way they were free to think about other more important things its just better if the worry of how to get to where you need to be is off your shoulders then you can actually start to focus on things that are really important the previous quote by mia suggests that the emotions attached to their struggle with the physical environment are sometimes so overwhelming that it takes up a lot of their head space leaving little room for anything else however these difficulties negotiating the physical environment was mostly only evident during the first few weeks of tertiary life as they became more confident in mastering their routes their worries mostly dissipated it was difficult but later … one morning you get up and you realise but listen here im doing it without thinking about it however this eventual comfort with the physical environment did not seem to have been fixed changes to the environment once again disrupted their lives sue for example recalled the way road constructions influenced her daily routine typically it took her ten minutes to get to class but with road works she had to leave time to negotiate the changed environment that time when they worked on the sidewalks that was a nightmare i walked 30 minutes before class started to be able to manoeuvre around it it was clearly difficult for the visually impaired students of this study to familiarise themselves with a new environment they often experienced emotional distress as they walked through large crowds of students tried to keep out of harms way and find their classrooms the relief of getting to know the university campus was also sometimes disrupted when the environment became unfamiliar once again through factors such as road constructions these often emotive accounts also point to the failure of some universities to make the physical environment accessible for visually impaired students it seems like the students mostly took it upon themselves to negotiate the environment none of the students reported any help from university staff in finding their way around university campuses the embodied experience of reading the students sometimes experienced difficulties with reading for the blind students who used braille reading was often timeconsuming since they were unable to visually scan through an article or book we have to read the entire article that is 60 pages whereas sighted people they use highlighters they use rulers they use pencils and they underline the most important things … and when they study they study the highlighted work … we have to concentrate more than sighted people and we cannot scan through our work we have to read everything subsequently most of these students needed extra time to complete assessments while extra time for examinations was usually granted quite easily it seemed like extensions for assignments were given on an adhoc basis they lecturers would tell you for example just see to it that you hand it in dont worry about the date just see to it that you hand it in … because they know it takes longer sometimes they lecturers allow extensions sometimes they are a bit mean and they dont what is more is the reality that requesting extensions for assignments was not always beneficial for the emotional wellbeing of the students i usually handed my assignments in late and that wasnt good for my morale laughs shyly because its humiliating asking for extensions all the time and youre scared that the lecturers might think you are lazy reading also held negative consequences for partially sighted students who typically read enlarged normal print for many of them reading was a marked embodied experience after long sessions of reading they commonly experienced strain on their eyes we have these four hour lectures and my eyes get terribly tired so that i start seeing spots when i concentrate for too long at times this physical strain was not restricted to their eyes for example emma commonly experienced migraines after long hours of reading then you have to lie in a dark room for a few hours and youve got a migraine its eye drops cortisone drops infections and so forth john experienced back pain from the way he had to sit while reading not only the stress on my eyes but the stress on my body that i experienced due to my eye problem how i had to sit or learn in school with my head almost on top of the desk and my back arched and the back problems i developed from that the bad posture and then i had to go and write exams for three hours with my nose against the paper these bodily manifestations of reading often had real consequences for the students it generally meant that they could not concentrate and focus on their reading for too long i avoid reading because my eyes get tired and then i get sleepy and then i am unable to concentrate later on your eyes get so tired that they cannot focus any longer consequently it was often difficult for the students to set their own pace and exactly for this reason john appreciated the flexible nature of his current dissertationbased postgraduate programme which was in direct contrast to the frequent deadlines of an undergraduate course for example the product i was able to deliver with my research was good and if i had only a short period of time to squash everything in and if i had to read a lot within a short period of time well then i dont think it wouldve been this easy doing it it is thus evident that reading was often difficult for the partially sighted students in particular their eyes quickly grew tired their bodies ached and therefore they were unable to concentrate and focus for long periods of time shameful and confusing bodies and the social world some students did not feel easily accepted by their peers it was the differentness of their disabled bodies they believed that made it difficult for others to welcome them into a friendship group people just find it easier to accept you if you are like them but given the undeniable and inescapable differentness of their bodies achieving some level of sameness was often very hard work it was kind of difficult showing people that even though i have a cane even though i cant see even though i sometimes dont know where i am i am still just like them i had to work hard to get their acceptance and to earn their trust and to you know to sort of get their interest partially sighted students also spoke about the hard work involved in gaining acceptance often their disability was invisible difficult to define and thus lead to misunderstandings in social interactions for example john said that people sometimes mistakenly thought he was rude when he didnt greet them while in actual fact he didnt recognise them socially it can also be difficult because i walk past people without recognising them uhm so people simply think that i am rude because i didnt greet them compensating for this john attempted various creative ways of recognising others but luckily now with time i start getting to know people and i learn to recognise them through other ways than their faces and so on … uhm i can sometimes actually see through the way someone walks or you get to know their voices a bit better or you see what clothes they wear in the morning and for the rest of the day you remember it but i think it happens unconsciously perhaps as a direct result of this differentness and the consequent difficulty in accessing friendship groups some students seemed to have the perception that their disability was shameful that it was an attribute that made them inferior to their peers so i dont even have a doubt that people will think that you fall short if you are friends with them that you fall short or that you will always be the ugly duckling or something like that ashley movingly recounted that her shameful unworthy difference was sharply illuminated by being placed in a hostel room with a beautiful seemingly perfect student because in my first year miss popular was my roommate she was miss varsity cup that year and she was miss varsity and she was a fashion model so she was really popular and very pretty so when i arrived there were always people in our room but it was for este people became friends with me to get to este discussion the embodied recollections of students confirmed the close ties between bodies and the world they live in the unfamiliar crowded and even dangerous physical environment erupted in their bodies as they experienced emotions like worry and fear aching bodies told of the strain to read while shame and exclusion pointed to social alienation and the intolerance of difference clearly as illustrated by this physiological and psychological pain the world was often not a comfortable home for disabled persons instead there was often a misfit between the design of the world and the shape of disabled bodies misfitting rippled their beingintheworld in some significant ways vicky for example acutely felt the residues of being different of being a misfit when she was around nondisabled persons she experienced that they saw her as the ugly duckling someone that was inferior to ablebodiedness we can safely assume that being the ugly duckling created feelings of shame and inferiority for her from her words it thus seems that the difference between her body and those of her peers reverberated in her very core in her sense of self for some students the misfit between their bodies and the world restricted their freedom and spontaneity mia avoided large crowds of students by staying on campus during lunch times even if she wanted to have lunch this option had to be weighed up against the emotional and physical effort it would have required of her in this way her freedom to choose from a broad horizon of possibilities was limited this lack of possibilities inadvertently turn the critical gaze to university policy and practices it is worrying that institutions that are supportive of diversity on policy level still fail to make their environments accessible to disabled students efforts to keep up with the demands of university life in other words efforts to fit were often timeconsuming recall for example sue who took 30 minutes to get to her class on a route that typically required only 10 minutes for some partially sighted students the physical pain and discomfort caused by reading also slowed them down as they could not set their own pace not only did they have to request extra time to complete assignments these requests also affected their emotional wellbeing and sense of self while it is true that a disability can extend the typical time of routine activities such as reading it can often be ameliorated through accessible environments in the following section we make suggestions that can help to overcome this disabling barrier the story that permeated all the abovementioned life examples was the various ways in which a disability and its misfit with the environment can influence a persons beingintheworld it shaped the way they looked at themselves it placed a lid on their freedom and it altered time these examples might create the impression that the requirements of the tertiary environment was always out of sync with the abilities of the students such an impression would not be accurate the results showed for example that the students gradually became more comfortable with the physical environment as they became familiar with their routes on campus sadly this seamless mode of living this casual beingintheworld did not mark the end of a process instead students fluctuated between fitting and not fitting in tandem with the ebbandflow of a rejecting and inviting world this was evident in recollections of lecturers who allowed extensions for assignments and others who refused such accommodations another example could be found in the disruption of the students growing ease with the physical environment when roads were reconstructed conclusion and recommendations from the results it is clear how bodily experiences can tell the story of personal struggle while still revealing disabling societal structures emotive accounts of worry and uncertainty for example unveiled some gaps in adequate provision for visually impaired students on tertiary grounds recognising these gaps now makes it possible to think about practical ways to address these incongruencies between disabled bodies and the world it highlights what is needed for change and reveals what accommodations are reasonable after listening to the stories of the students we make three practical suggestions getting around the campus and learning the routes to their classrooms were clearly an immediate and sometimes ongoing concern for the students an orientation programme specifically directed to teaching visually impaired students the physical layout of the campus may be very useful and might help to alleviate the emotional distress associated with those first few weeks on campus yet an initial onceoff orientation programme will probably not be sufficient to address all their mobility needs such as unexpected changes to the physical environment we therefore suggest that universities consider employing mobility instructors as part of their disability support team the differentness of their bodies and the concomitant experience of shame and rejection was a reality for many of the visually impaired students from early on disability support staff can make active efforts to combat possible social isolation for example they can launch campaigns to raise awareness around disability for nondisabled students and inform visually impaired students of accessible social activities on campus such as chess choir and so on of course it would be naïve to assume that such efforts will eliminate shame and rejection altogether but it might create a platform to build friendships and gain the invaluable feeling of acceptance in fact in some studies disabled students pointed to their nondisabled friends as an invaluable source of emotional and practical support lastly in the light of the physical pain caused by reading we recommend personal readers andor audio books for partially sighted students another issue that needs to be taken into account with regards to reading is that it is mostly not possible for visually impaired individuals to skim through text listening to audio recordings will make this impossible it might therefore be useful to consider formalised extra time for assignments listening to the voices of disabled students therefore seems to be essential in ensuring that they are fully included on university campuses when their daily experiences are understood and documented it will be possible to begin to design a world in which their bodies will find a better fit

although previous literature sheds light on the experiences of visually impaired students on tertiary grounds these studies failed to provide an embodied understanding of their lives indepth interviews with 15 visually impaired students at one university demonstrated the ways in which they experienced their disability and the built environment in their bodies at the same time lost fearful shameful and aching bodies revealed prevailing gaps in provision for disabled students through this research it becomes clear how the environment is acutely felt within fleshly worlds while bodies do not fail to tell of disabling societal structures based on the bodily stories we thus make recommendations to improve the lives of visually impaired students on tertiary campuses

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aims social psychiatry faces a challenging relationship with pop culture understanding pop culture portrayals of mental health culture could be valuable to public mental health top boy is a fictional show touching upon the experience of individuals living in the grip of a mental health syndemic in innercity london methods as wq had structured discussions to analysing themes social determinants and psychiatric correlations in top boy results top boy touches on aspects of mental health including immigration the impact of violence the impacts of urbanicity and deprivation syndemics domestic abuse and ptsd violence as a trigger for ptsd is illustrated in the story of jason a young child who is exposed to domestic violence resulting in avoidance of this environment and association with gangster sully jason becomes desensitised to violence greater ptsd is linked with violence in a dosedependent fashion sully watches jason die after a racially motivated attack illustrating the nested nature of such trauma as sully develops ptsd he is seen reexperiencing the fire sully can later be seen to be hyperaroused to perceived threat exposure to violence particularly in the context of gang membership is strongly associated with anxiety disorders impacts on relationships and childhood neglect are explored through ranell and lisa lisa is a single mother whos survived an abusive relationship she becomes severely depressed resulting in her being sectioned and an extended psychiatric admission ranell her son falls into the narcotic trade leading to truancy and violence his friend gem is seen to try drugs when forced to act as a mule involvement in the drug economy leads to drug dependence among gang members these come together in the estate syndemic psychiatric morbidity is exacerbated synergistically with health inequalities caused by poverty stress structural violence and racial discrimination this leads to educational disadvantage through truancy in the cases of ranell and ats whos mother suffers from the mental health effects of unemployment and deportation threat individuals are then more likely to interact with gangs in this syndemic environment and so the cycle of illegal activity violence and ill health perpetuate conclusion gang members currently will make a large contribution to mental health disability and service burden in syndemic areas top boy illustrates the challenge and opportunity for public mental health in the context of such syndemics abstracts were reviewed by the rcpsych academic faculty rather than by the standard bjpsych open peer review process and should not be quoted as peerreviewed by bjpsych open in any subsequent publication aims several studies on simulation as a method of teaching have identified advantageson attitudes skills knowledge and behaviours and nontechnical skills such as situational awareness team working interpersonal interactions with improved confidence use of simulation in psychiatry is growing but studies are limited we decided to evaluate our own delivery of simulation in trust and align this to the national strategy to identify gaps and further work methods what are we offering now is simulation a

relevant and as realistic as possible to existing trainees the final stage of the project was november 2021 which involved filming with the production company and professional actors who brought our concept to life postproduction we presented them during trust academic program to launch the videos in mid2022 results the videos were received positively and quantitative scores completed by a questionnaire before and after showing the videos showed an improvement in confidence in assessing managing and treating patient with physical health issues and those with physical health complications of their mental health in a psychiatric hospital from 39 to 88 response rate 6290 conclusionrecommendations we are proud to report that these videos are now being used during every junior doctor induction and can be referred to if a refresher on that topic is required later we are excited about this innovative method of training using highquality videos to ensure trainee engagement we hope it will form a baseline for further discussions and teaching around the topics derived from the scenarios the videos were designed to last many years and so we hope will be of benefit to current and future trainees of all levels this successful project will be expanded further and we are in the process of developing other scenarios that can be used for training abstracts were reviewed by the rcpsych academic faculty rather than by the standard bjpsych open peer review process and should not be quoted as peerreviewed by bjpsych open in any subsequent publication

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introduction the number of covid19 cases in many countries around the world continues to increase since the first outbreak was reported in december 2019 1 the japanese government declared a nationwide state of emergency on april 16 2020 due to the rapid increase in the number of covid19 cases 2 as such public and recreational facilities were closed and japanese citizens were instructed to stay at home moreover social distancing measures were implemented nationwide thus requiring people to maintain a distance of approximately 2 m from one another and to avoid crowded places and unnecessary social gatherings despite the benefits many studies reported that such a public health measure affected the physical and mental functions of older adults 3 4 5 in japan the time allotted for physical activity among older adults decreased by approximately 30 during the state of emergency compared with before the spread of covid19 which prompted people to refrain from various activities 6 suzuki et al 7 found that a decrease in physical activity before the covid19 pandemic was strongly associated with a decrease in subjective health among communitydwelling older adults in japan one of the reasons for this change may be the decreased frequency of socialization among communitydwelling adults aged 60 and over due to social distancing measures based on the literature 89 the current study defined socialization as moving from ones residence to another place or region in this study covid19induced changes in the fos were operationally defined as decreased or increasedunchanged fos moreover the fos reflects the social activities of older adults such as their roles inside and outside the home leisure activities and interactions with others 10 furthermore yasunaga et al 11 used accelerometers to demonstrate that increased opportunities for socialization lead to more time for moderate physical activity among older adults so an association with the fos may be predicted the results suggest that increasing the fos among communitydwelling older adults is an important factor in promoting physical and social activities and preventing confinement and frailty however studies that investigate the types of changes in daily life social life and physical factors that influence the fos among communitydwelling adults over 60 years of age due to the covid19 pandemic are lacking to address this research gap the present study aims to understand the changes in the fos due to the covid19 pandemic among communitydwelling adults aged 60 and over in relation to changes in daily life social life and physical function this form of intervention may contribute to the maintenance and improvement of the health of communitydwelling adults aged 60 and over whose socialization is restricted by covid19 measures materials and methods study design the study is crosssectional in nature and employed a selfadministered questionnaire ethical considerations the participants were duly informed about the purpose of the study moreover the researchers assured them that information collected will remain confidential and be used only for the study by answering the questions in the questionnaire the respondents indicated their agreement to participate this study protocol was approved by the coop kagoshima compliance committee in september 2020 questionnaire structure the questionnaire was developed by three skilled occupational therapists after content validation a set of questions was developed based on the international classification of functioning disability and health items with body structure body function activities and participation as factors that influence changes in the fos the questionnaire was presented with the following structure social demographics and baseline characteristics health history daily life changes social life changes and physical health changes this questionnaire did not ask for identifiable personal information data were strictly controlled by answering and returning the questionnaire the respondents consented to participate in the study the survey items in each section are outlined below social demographics and baseline characteristics this section included information on age sex height family structure and occupational status the subjects were instructed to select the appropriate responses for the all questions health history the subjects answered questions about underlying diseases eg hypertension diabetes hyperlipidemia hyperuricemia osteoporosis cancer cardiovascular diseases cerebrovascular diseases parkinsons disease depression dementia collagen diseases spinal diseases thyroid diseases respiratory diseases osteoarthritis ophthalmic disorders questionnaire structure the questionnaire was developed by three skilled occupational therapists after content validation a set of questions was developed based on the international classification of functioning disability and health items with body structure body function activities and participation as factors that influence changes in the fos the questionnaire was presented with the following structure social demographics and baseline characteristics health history daily life changes social life changes and physical health changes this questionnaire did not ask for identifiable personal information data were strictly controlled by answering and returning the questionnaire the respondents consented to participate in the study the survey items in each section are outlined below social demographics and baseline characteristics this section included information on age sex height family structure and occupational status the subjects were instructed to select the appropriate responses for the all questions health history the subjects answered questions about underlying diseases the subjects were asked to answer the items corresponding to their previous diseases in a multipleresponse format more than one answer could be provided the number of responses was used as the number of underlying diseases daily life changes this section inquired about changes in the fos before and after the outbreak of the covid19 pandemic in japan we first asked how has your frequency of going out changed compared to before the covid19 pandemic participants were asked to choose one of the following options increased decreased and unchanged then the respondents indicated whether a change was noted in the frequency or duration of activities related to daily living before and after the covid19 pandemic the questionnaire consisted of a total of 15 items according to two categories the first included selfcare and activities of daily living with the following items frequency of bathing cooking urination and defecation hours of sleep nap bedtime amount of food and time of day to eat the second category focused on instrumental activities of daily living which consisted of the following items frequency of shopping cleaning laundry number of phone calls hours engaged in phone calls amount of trash and frequency of missing medicine each question was answered using the following options increased decreased or unchanged for questions related to frequency and longer shorter or unchanged for questions related to duration social life changes this section consisted of 10 questions according to the two following categories questions under the first category were related to work and hobbies and consisted of the following items time spent on hobbies and interests roles and tasks at home commuting to work and leisure the second category included interpersonal interaction and consisted of the following questions opportunity to meet with friends and neighbors time to talk to friends and neighbors gatherings family communication eating out and communication via the internet the questions were answered as follows decreased increased and unchanged physical health changes in this section the following items were used to investigate physical health before and after the covid19 pandemic the first was related to weight changes the participants had to choose one of three options namely gained lost or unchanged the second pertained to changes in physical activity with three options namely increased decreased or unchanged the third referred to ones feeling of comfort with ones body the participants answered yes or no statistical analysis the answers were tabulated by category and divided into two groups decreased fos and increasedunchanged fos a crosstabulation table was created the basic information and proportion of responses to each question were then compared students ttest was used for continuous variables whereas the mannwhitney u test was used for ordinal scales moreover pearsons chisquare test was used for categorical variables whereas fishers exact test was used to compare answers when the crosstabulation table reached a point where more than 20 of the cells displayed the expected value of less than 5 1415 subsequently residual analysis or multiple comparison was used as a post hoc test for items with significant differences across categories in addition nonlinear logistic regression analyses were employed to examine the relationship of the fos to daily life social life and physical factors that influence the fos two regression models were used namely the crude and adjusted models for each model the fos was set as the dependent variable however for the crude model questions that exhibited significant differences across categories were individually set as independent variables meanwhile the adjusted model adjusted for potential covariates such as age gender family structure occupation status and underlying diseases spss ver 260 and r version 403 16 were used for all analyses p 005 was considered statistically significant results characteristics of the participants table 1 presents the characteristics of the participants out of 342 adults aged 60 and over 233 experienced decreased fos this group was younger than participants with increasedunchanged fos no significant differences were observed in terms of other demographic factors between the two groups comparison of questionnaire items by frequency of socialization table 2 displays the results of the crosstabulation bivariate comparison and post hoc analysis according to the fos in terms of daily life changes the increasedunchanged fos group was more likely to report significant increases than the decreased fos group in the following aspects bathing cooking urination and defecation frequency or duration of phone calls and amount of trash in addition the decreased fos group displayed a significant decrease in the frequency of shopping in the increasedunchanged group the following items were more frequently reported as unchanged before and after the covid19 pandemic bathing cooking urination and defecation shopping frequency or duration of phone calls and amount of trash table 3 displays the results for social life changes the following items were found to be more frequent in the decreased fos group compared with the increasedunchanged fos group time spent on hobbies and interests commuting to work leisure opportunity to meet with friends and neighbors time for conversations with friends and neighbors gatherings family communication eating out and communication via the internet the decreased fos group reported significant increases in the frequencies of time spent on hobbies and interests roles and tasks at home and communication via the internet conversely the increasedunchanged fos group reported a significantly increased frequency of eating out in addition the increasedunchanged fos group mentioned the same frequencies for time spent on hobbies and interests roles and tasks at home commuting to work leisure opportunity to meet with friends and neighbors time for conversations with friends and neighbors gatherings family communication eating out and communication via the internet before and after the covid19 pandemic 4 presents the results of physical health changes in terms of weight the decreased fos group pointed to an increase compared with the increasedunchanged fos group and the decreased fos group pointed to a significant decrease in physical activity in addition the increasedunchanged fos group reported no significant changes in weight and physical activity relationship of fos to daily life social life and physical function table 5 provides the results of univariate and multivariate logistic regression analyses for both groups univariate logistic regression analyses indicated decreased frequencies for cooking meals shopping family communication and eating out which were significantly related to the fos according to the crude model after adjusting for potential covariates the decreased frequencies of cooking meals shopping and eating out were significantly related to the fos according to the adjusted model discussion the crosssectional study conducted a questionnaire survey to understand changes in the fos among communitydwelling adults aged 60 years and over following the declaration of the state of emergency in japan as a response to the covid19 pandemic the study investigated the relationship of the fos to changes in daily life social life and physical function the results reveal that decreased frequencies of cooking meals shopping and eating out were associated with the change in the fos among communitydwelling adults aged 60 years or older even after adjusting for potential covariates thus the results suggest that a set of daily living items should be prioritized to minimize the decline in the fos among communitydwelling adults aged 60 and over the government prescribed selfisolation among older adults as a part of movement restraints given that older adults are more vulnerable with age the willingness for proactive selfisolation peaked among adults in the 7075 year age group which gradually increased among those aged 70 years 17 similarly the results of the current study indicate that the decreased fos group was significantly younger than the increasedunchanged fos group this finding suggests that positively refraining from socialization may have resulted in decreased fos among the young older participants therefore the study inferred that although adults aged 60 and over actively observed the measures for covid19 prevention they continued to avoid densely populated areas such as supermarkets the aspects of daily living include selfcare adls and iadls the previous study 18 proposed that older adults maintained daily life at a minimal level due to covid19 in contrast the present results reveal that the frequency for selfcare remained nearly the same in the decreased and increasedunchanged fos groups increases in the frequencies of bathing and elimination were observed only for the decreased fos group this finding is assumed related to the increased time spent at home 19 the results reveal that fos is significantly associated with frequencies of shopping and cooking the reason for this finding may be that the majority of shopping activities involve socialization moreover the study infers that less frequent cooking may indicate more time spent outside the home conversely the restriction on eating out led to the assumption that they cook more frequently at home in the decreased fos group longer times spent at home may result in more food to eat and rubbish to clean and more frequent and longer durations of telephone calls for social interaction furthermore the high or in the multiple linear logistic regression analysis of shopping frequency suggests that the majority of socialization for communitydwelling adults 60 years or older was allotted for shopping makino et al 20 argued that limitations in outdoor iadls were associated with the development of mild cognitive impairment which points to the need for support of the maintenance of iadls to prevent cognitive decline in recent years online services have enabled users to order daily necessities via the internet which can be delivered to their homes even before the decline in the frequency of shopping studies in japan recently recognized that many older adults use the internet for similar reasons such as shopping and banking 21 however enhanced support for iadls including shopping will be required in the future as people aged 60 years and above selfisolate to prevent covid19 infection social factors included work hobbies and interpersonal interactions the results demonstrate that the decreased fos group reported significant declines in the majority of items related to social life interestingly the proportion of people with increased time spent on hobbies and interests roles and tasks at home and communication via the internet was significantly higher in the decreased fos group the reason underlying this result is that adults aged 60 and over in the decreased fos group may spend more time at home due to the restrictions on socialization thus lending more time for hobbies and tasks in addition they may use the internet more frequently as an alternative means of interpersonal interaction alternatively many adults aged 60 and over in the increasedunchanged group were originally engaged in hobbies or tasks at home moreover the present study found that the frequency of eating out was significantly associated with decreased fos thus the study infers that family and friends typically accompany older adults when eating out which is considered to provide opportunities for social interaction and support by promoting participation in shared social activities during meals 22 in older adults reduced social interaction due to the covid19 pandemic was associated with loneliness and depression 23 in addition communitydwelling older adults who were less satisfied with important activities were at high risk of exhibiting depressive symptoms 24 thus implying the importance of maintaining certain activities such as hobbies and interpersonal interaction despite the covid19 pandemic nevertheless the need to take infection control measures such as maintaining a distance of approximately 2 m 25 and wearing a mask 26 remains for activities that involve contact with people therefore when providing social support for adults over the age of 60 implementing preventive measures is necessary in addition to hobbies and interpersonal interaction the current situations require people to maintain physical distancing to prevent infection however internetbased assistive technologies have been developed and reported to significantly reduce loneliness and increase social support and wellbeing in older adults 27 thus their widespread use is expected the aspects of physical function pertain to weight physical activity and subjective health the results indicate that the decreased fos group reported significant weight gain and reduced physical activity compared with the increasedunchanged group di santo et al 28 found that 35 of communitydwelling older adults gained weight due to the covid19 lockdown and such inactivity is a highrisk factor for impaired health and may lead to a state of sarcopenia which is a combination of weight gain loss of skeletal muscle mass and muscle weakness 29 moreover other studies demonstrated that psychological problems precede physical problems in older adults as a result of the covid19 pandemic 3031 in the present study 21 of the participants reported weight gain which is a slightly lower value than that in previous studies multiple logistic regression analyses suggested an association between an increase in physical activity and the fos however no significant differences were identified apart from demographic factors such as being female and older age the relationship of lifestyle factors such as increased consumption of sugary drinks and fried foods increased frequencies of eating and snacking decreased physical activity and increased alcohol consumption to weight gain during the covid19 pandemic was identified 32 moreover the results illustrate differences in the amount of activity dependent on the fos for example 31 of the participants reported a decrease in physical activity whereas only 5 increased their activity older adults who became more active during the covid19 pandemic reported an increase not only in certain activities such as housework but also in light exercises and sports such as walking and flexibility exercises 7 thus formulating a method for addressing the lack of physical activities among adults 60 years or older who refrain from socialization for covid19 prevention is necessary limitations the present study has its limitations first the subjects were coop members aged 60 years or older and living in kagoshima prefecture moreover the response rate of this questionnaire survey was somewhat low and subjects may be limited to adults age of over 60 years with relatively fair cognitive function and physical function that allows them to complete the questionnaire and post it to the mailbox thus a possibility of selection bias exists which limits the generalizability of the study second changes in daily and social activities and physical function were selfreported and retrospective which may led to recall bias third confirming the causal relationship of the fos to daily life social activities and physical functions is impossible due to the crosssectional nature of the study thus a longitudinal study should be conducted to confirm this relationship lastly the need emerges to expand the scale of the study by recruiting participants from other districts conclusions the study found several differences between decreased or increased fos and the daily and social activities and physical function of communitydwelling adults aged 60 and over among the participants young older adults were more likely to report decreased fos this finding suggests the need to maintain certain levels of adls and iadls even before the covid19 pandemic and the need to counteract weight gain and decreases in social or physical activities in adults 60 years or older in the decreased fos group specifically activities such as cooking shopping and eating out were significantly related to the fos the authors believe that the results can provide a reference and resources to aid in the daily lives of communitydwelling adults over the age of 60 during the covid19 pandemic informed consent statement informed consent was obtained from all subjects involved in the study

the study is crosssectional in nature and aims to investigate the relationship of the frequency of socialization fos to the daily life social life and physical function of communitydwelling adults aged 60 and over after the covid19 outbreak a selfreported questionnaire survey was conducted on 3000 members of coop kagoshima out of which 342 responses were received bivariate statistics was conducted followed by multiple logistic regression analysis questions with significant differences were set as independent variables whereas the fos was set as the dependent variable results indicate significant group differences between the decreased and increasedunchanged groups after adjusting for potential covariates multiple logistic regression analysis revealed decreases in the frequencies of cooking or 007 95 ci 001069 p 002 shopping or 1876 95 ci 7124941 p 001 and eating out or 347 95 ci 121997 p 002 which were significantly associated with decreased fos the finding may inform policy making in identifying priorities for support in daily life for communitydwelling adults over the age of 60 undergoing social distancing

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background this study was undertaken in rural communities on the outskirts of peshawar in north west pakistan many community members live and work on brick kilns and have an average income of less than one us dollar a day the mixed population of local pakistanis and longterm afghan refugees are mostly from the pukhtoon ethnic group with a traditionally tribal and patriarchal culture this wellcome trust funded project was conducted as part of a longterm collaboration between the abaseen foundation pakistan a locally operating nongovernmental organisation and ukbased universities for a number of years to improve health wellbeing and education in pakistan 1 2 3 in pakistan very substantial differences persist between regions and different socioeconomic groups in access to resources for health improvement 4 a small percentage of educated andor wealthy pakistani families have access to healthcare and health promotion information but many do not 5 many people live below the poverty line in unsanitary conditions with limited access to clean water are poorly educated and have unequal access to education and healthcare 56 the project reported here focussed on the role of the jirga in engaging the community in health improvement despite these challenging contextual conditions the jirga is a traditional informal structure which gathers men respected within their community and acts in a governing and decisionmaking capacity in the pukhtoon culture 78 in spite of the launch of pakistans national iodine deficiency disorders control programme in 1994 approximately half of pakistans population of 200 million are affected with iodine deficiency disorders 9 a national nutrition survey revealed marked provincial variation with for example 257 of children aged 612 years at risk of iodine deficiency in the north western province where this project took place 10 to build on this we conducted a baseline household survey in mayjuly 2012 including 1043 local households it showed in particular that 97 of households did not use iodised salt and reported not to understand its benefits a jirga was called to share the findings and discuss what could be addressed within the timescale and funding parameters of this project this led to the development of a multicomponent awareness raising campaign promoting the benefits of iodised salt to improve knowledge attitudes and practices in the area the overall project this project involved a team of researchers in the uk a research lead in pakistan and pakistanbased research assistants and the abaseen foundation all ukbased researchers have doctorates and a combined wealth of experience in qualitative and quantitative research methodologies and the lead pk researcher has an md and a long term engagement with the team with such a widespread geographical area and broad expertise regular communication loops were key to the success of the project in particular to ensure that the model was not directed by ethnocentric conceptualisations and understandings of community engagement but led by the pakistanbased team this was operationalised as a twoway communication loop with weekly skype meetings being held between the pakistan and ukbased researchers and additional skype training sessions being offered by the uk team in qualitative methodologies the following steps were used in the design implementation and evaluation of the intervention step 1 focus group discussions were conducted with community members to gain a greater understanding of the knowledge related to iodised salt its intake and local availability and the role of different stakeholders in promoting its use step 2 the intervention a multicomponent community awareness raising campaign was implemented over a 4month period from june to september 2013 step 3 a survey of local shopkeepers was undertaken prior to the start of the intervention and during the intervention to collect data about the types and quantity of salt sold its storage packaging and pricing further monitoring of sales was conducted on a monthly basis step 4 the intervention was evaluated ○ quantitatively based on salt sales figures and through the urinary iodine concentration of school boys aged 612 years taken at three time points 11 ○ qualitatively using a postintervention semistructured questionnaire to collect data on knowledge attitudes and practices towards iodised salt and its use the evaluation has been published separately 11 iodised salt sales and uic were monitored to assess the effectiveness of the intervention at baseline 26 of households reported use of iodised salt during the intervention sales of salt labelled as iodised increased by 45 however this was not reflected in an increased uic therefore whilst the intervention was successful in terms of raising awareness and changing behaviours issues remain regarding adequate iodisation by local producers and appropriate storage of salt this paper describes the community engagement process undertaken to ascertain the focus development and implementation of the intervention situating this in the broader literature on community engagement in health improvement iodised salt is thus used here as a case example for future engagement and health improvement interventions in culturally specific settings the paper adheres to the coreq guidance on reporting community engagement and health improvement the fact that community participation is a key factor in successful health promotion initiatives has long been acknowledged internationally 12 13 14 broadly speaking models of engagement have been conceptualised along a hierarchy of levels ranging from nonparticipation information giving through to consultation joint decisionmaking and full community control or self mobilisation 15 16 17 whilst the difficulty of evaluating the impact of community engagement initiatives has been widely acknowledged because of the great variety of approaches and settings 1518 there is now solid evidence that they have a positive impact on a range of health outcomes such as health behaviours health consequences participant selfefficacy and participant social support 1920 a recent metaanalysis of community engagement highlighted that interventions that engaged the community in delivery as those with the largest pooled effect size 19 change is then believed to be facilitated by the credibility expertise or empathy that the lay community member can bring to the intervention delivery 21 whilst it has been acknowledged that many interventions use combinations of engagement methods 15 much of the research undertaken todate has focused on developed countries this article responds to calls to document with greater clarity community participation strategies used in health promotion research in order to maximise translation potential to other contexts 414 we focus on a particular sociocultural context in north west pakistan and describe the relationships between this context and the possibilities and constraints related to community engagement work the pukhtoon jirga system has been defined as a gathering of all men concerned with a specific issue plus others who are respected or influential locally 22 representation in the jirga is based on alliances lineage patronage andor cultural value orientations and is thus fluid and topicspecific without the backing of community leaders and representatives through this system it would have been impossible to conduct the research however communication channels and levers of influence on health behaviour like in many other societies are multiple and complex and all needed to be taken into consideration in order to ensure successful and locally sensitive community engagement the jirga system had a dual purpose for the study to access men from the community and discuss the importance of iodised salt and as an engagement process for the intervention objectives the objective of the study was to explore the naturally occurring communication and influence channels in the local communities to ensure effective engagement in a programme to promote increased use of iodised salt methods drawing on principles of ethnography qualitative data were collected as part of step 1 described above focussing on 1 the jirga their members and immediate networks and 2 broader community groups unless otherwise stated the sampling strategy was purposeful drawing on the web of relationships mz and afpk already had in the community and therefore we had no case of refusal to participate interview guides were developed collaboratively between the uk and pakistanbased teams and tailored to the participant activity 1jirga members over a period of 15 months from march 2012 to june 2013 afpk called seven jirgas to discuss operational activities related to community development jirga members were selected on the basis of their experience and reputation and invited to participate by the male research assistant to attend both verbally by visiting their homes or work place one week before and also by reminding them by mobile phone the day before the jirga took place apart from one all jirgas were audiotaped after obtaining consent from the participants and they lasted approximately 90 min proceedings of the jirgas were facilitated by mz recordings were transcribed and translated into english anonymised and analysed using nvivo 10 in addition onetoone interviews with four jirga members and a focus group with nine jirga members were conducted in the local community hospital to gain a greater understanding of the jirga system and its role in community development particularly in relation to health improvement for the interviews a list was compiled with the assistance of local school teachers of sixteen men who were active members of jirga within a 5 km radius of the local health centre a random sample of four jirga members was selected they were invited to take part and all agreed three interviews took place in the local hujra and one at the participants home they lasted 30 min on average for the focus group participants were recruited using a snowballing sampling method from one afpk member semistructured interviews were also undertaken with the wives of jirga members to investigate if and how jirga discussions were shared with the community four jirga members were approached to seek their permission for the female pakistanbased research assistant to interview their wives the four households were visited wherein the purpose of the study was explained consent obtained and semistructured interviews conducted a total of eight women were interviewed from these four households whose ages ranged from 35 to 70 years in order to protect their anonymity no direct quotes are reported in this paper but rather the researchers notes following a discussion activity 2community groups fgds were conducted with different community groups to gain a greater understanding of the role of jirga members in promoting health locally these included 1 women under 40 years old 2 women over 40 years old 3 lady health workers 4 male informal healthcare workers the rationale for selecting two distinct groups of women was based on the premise that older women often make healthcare decisions for the family sampling was purposeful four fgds were thus conducted each lasting approximately 40 min due to cultural constraints the female research assistant facilitated three fgds with female participants and the male research assistant facilitated one fgd with male participants fgds were held with nine women over 40 years old and eight women under 40 years old in november 2012 two further fgds involving seven female outreach workers and eight male informal healthcare workers were conducted in december 2012 and march 2013 respectively analytical strategy apart from one jirga and one facetoface interview where consent to record was declined all interviews and focus groups were audiorecorded and additional field notes were taken recordings were transcribed and translated into english anonymised and thematically analysed using nvivo 10 this involves coding the data to extract basic themes these are then collated into organising and finally global themes 23 these included agency communication jirga membership poverty power and hierarchy religion and traditions data was coded and analysed inductively by both the pakistan and ukbased research teams which included a triangulation of findings between the different participating groups this was a highly iterative process whereby the comprehensiveness of the data was thus ensured and any gap in knowledge addressed through discussion with the pakistanbased team the transcripts were not returned to research participants as this research was not about eliciting individual but communal experiences and the pakistanbased team ensured the validity of all of the cultural understandings developed from the data and reported here results it was important for the research team to develop a thorough understanding of the local channels of communication and influence to understand how to communicate information in the most effective way a number of themes emerged from the data pertaining to the decisionmaking processes in the family communication channels in the community and then more precisely in and around the jirga these are detailed in turn below decisionmaking in the family environment throughout the project the pakistanbased researchers provided regular clarifications and notes of cultural sensitisation for the ukbased team they highlighted the following family hierarchy if the male head of family is alive he has the power to make all family related decisions without consulting any family member the older he is the wiser he is considered to be and the less likely it is that his decisions are disputed where the head of family has passed away or is absent that role is passed on to the oldest woman of the household who will usually make decisions in collaboration with her eldest son if the son is old enough to be married and considered mature then he takes on the role of head of family this is represented in fig 1 community members are grouped by gender and placed in order of decreasing decisional power younger women explained this further in relation to grocery shopping and the local customary restrictions over their movements who brings groceries for you men so when men are out of homes then what do you do then we ask the children or men of the village to go to the market and bring us groceries or whatever it is that we need so when men and children both are not around then how do you manage to buy groceries from the market then we ask from one another to share with us their groceries women of this area do not go out to buy groceries whilst physically going to the market was the remit of men and boys the decision as to what had to be purchased varied somewhat … in rural areas people are not educated so the decision is made by men of the house educated women just hand over a list of required items to their male counterparts to buy and bring the required items younger women agreed that on the whole locally men were key decision makers when it came to grocery shopping men bring whatever they like we cant ask anything about whether you should bring iodine salt or simple salt and we just use whatever he brings home if women complain about the type of groceries the men bring in they feel offended and threaten to not bring it all this was corroborated by participating men obviously the male member should go and also decide the type of salt to buy… as he has to pay for it … the women are very simple village type so whatever we bring home they use it this key decisionmaking role meant that we ensured men were engaged in our iodised salt awareness raising activities a number of traditional beliefs emerged through the data which reinforced the need for us to engage the most influential community members in the intervention these linked goitres to throat infections depression or the consumption of unclean water and a fear that iodised salt may lead to birth control older women highlighted how the lines of communication between genders although bound by clear traditional rules are not always straightforward and there are clear exceptions the normal salt is wrapped in a smaller packet which is cheap whereas the iodised salt is in a big packet my wife … asks me to bring the big packet even though the small packet is cheaper older women in particular could clearly be influential in family decision making my grandmother once had goitre so now whenever we need salt in the house she tells us to bring iodised salt only… she knows the importance of iodine salt and the problems connected with the deficiency of iodine on domestic issues mothersinlaw hold considerable decisional powers as was described in one of the jirgas a lady who had some health problem … came to our home with her motherinlaw for spiritual treatment i told her that prophet said that … if a person recites chapter fatiha seven times on the ill person … so god will heal him… i told that motherinlaw that besides doing this take her to doctor as well so i told her that you dance in your sons wedding and beat the drum so then take this unfortunate to a doctor who is someone elses daughter so that she gets fine so she replied me… god will heal her and that motherinlaw just wants not to spend the money of her son… two key points emerge from this quote the fact that mothersinlaw make decisions when it comes to the health of younger brides and the fact that in the community older women do communicate with and question older wiser men communication channels in the community we sought to understand the most effective communication channels beyond the family in relation to we sit in our hujra every night almost 20 to 30 people… sometimes we hear a case of a child having iodine deficiency and i tell them that its because of iodine i tell them but they dont listen women sometimes can communicate with the community at large through the male members of their family well my 13yearold son goes to mosque you can write me down the message and i will give it to him to post it in the mosque or distribute it to everyone i am not educated but others are we can spread this message in the house of allah its a very right thing to do religious leaders are highly regarded in all matters including health if ulema religious leader say something like this iodised salt everyone listens to him because he is very influential women under 40 years old who traditionally have very little decisional or influential powers suggested ways in which a health message about using iodised salt may be spread effectively we can inform our neighbours relatives whoever we meet about the uses and benefits of iodine salt we will also inform our men who can also spread the message amongst their friends relatives people in mosque and hujra teachers can inform children about the use of iodine salt who can then pass the information to their parents… thus it appears that younger women may not solely be the passive recipients of others decisions but gladly offer to spread the message among their peers women can talk to women of their age and standing and occasionally speak to men who can then spread the message through their male networks education and influence on children is also clearly valued other channels were suggested there is not much tv here but everyone has a radio and it would be very helpful if they run it on radio doctors can inform all the women who come and visit the hospital whilst the radio was a valued communication means for women who might spend extensive amounts of time at home men favoured word of mouth we do not listen to radio but mostly talk among ourselves enjoying warmth of sun men made similar suggestions for the effective spread of a health education message emphasising the use of influential and respected community figures though not clarifying how the message would then reach women like the imam of mosque may talk during friday sermons … regarding the use of iodised salt and its positive effects on the health of children and the whole household the school teacher can tell the students in a formal lesson and highlight the benefits and also the problems caused if not used in the same way the hujra elders can inform the younger people in cases where the gravity of the situation calls for it or when male relatives are absent women are able to talk to older wise men in order to resolve an issue my wife listens to the female when she comes personally to the jirga… sometimes i listen to the female… these people are afridi by tribe and by profession they are drivers… they come to home after one month this lady stopped me in the middle of the road… and said that someone has forfeited her property by force and transferred it to this name … i … reached to those people to whom the woman accused those people were very influential one of them was refusing but i took the authority and declared the final decision after a week her husband came to me and thanked me a lot to have finalised the matter in his absence it transpires from this data that lines of communications do not solely depend on a persons standing within the family or community but particular venues can form key communication vehicles too this is represented in fig 2 venues are colour coded so that the darker ones exert the greatest influence on attendees red arrows show lines of influence imams influence peoples behaviours through their communications at the mosque which is mostly attended by men young and old men also gather at the hujra where wiser men counsel younger ones the grey arrows indicate lines of communication through which information is disseminated male health care professionals working in health centres have influence on adult men and may impact on health related decisionmaking in the family they may also disseminate information on improving health behaviours to women patients shop owners radio stations and school teachers mostly have a role in the dissemination of a health promoting message communication also happens directly through the ranks of decisional powers often echelon by echelon but not always as the data shows the levers for community engagement are therefore linked to social influence through gender age religion wealth and education fgd data was crucial for understanding barriers to the use of iodised salt and helped in designing an intervention that would activate the key levers to decisionmaking in the community this resulted in a multicomponent awareness raising campaign that included the design and distribution of leaflets and posters at the mosque hujra health centres and schools to shopkeepers and informal healthcare providers and to households brick kilns and communal areas health education sessions were also given to groups and individuals in addition a radio interview with the pakistanbased project lead was broadcast on the local radio station such comprehensive approaches to information dissemination and social mobilisation is in line with recommendations found in the literature 4 communication within and around jirgas since the jirga system was a prominent part of the local communities it was important to understand modes of communication within and around it in their field notes the pakistanbased research assistants noted the working of the jirga before the jirga each member meets each other… in a traditional way by shaking hands and hugging each other in a smiling mood and also asking about each others life that how is life going on asking about each other family members and work… the jirga was started with the recitation of the holy quran after that all the event was gone in a very light mood all the members give respect to each other and listened to each other very carefully … focus group members described the function and status of the jirga as a gathering of elder or respected community members who often meet to resolve local conflicts if someone has any problem then elders of the locality get together to find out the solution of the matter the right solution the respect inspired by decisions taken at jirga level was very apparent in the data further explanation is given below about the community function of such resolution if for example someone kills anyone and his elders go to court and police captures the accused role of the court is to give punishment to a prisoner still the system doesnt turn their dispute into friendship so this is the difference jirga tells them to live friendly and brotherly jm02 qualified this with an example of the jirgas emphasis on community cohesion once my brother had a clash with someone … they had fight and my brother shoot few people of other party when i came to know about this clash i ran quickly and took all the injured people to the hospital for treatment before knowing and reaching the family members of the other party my brother was killed… after the death of my younger brother… the elders of the village gathered at one place and we did the jirga jirga decided that i will give him two hundred thousand rupees and will arrange a dinner for the whole jirga along with two sheep on the day of jirga i took all the things but other party returned other cash and took only one sheep and arranged the dinner personally for the entire jirga thus our clash turned into friendship till today we are living happily my nephews sit together with them participants described how the function of jirgas had evolved from mostly being about conflict resolution to including a greater emphasis on social aspects of community life the social work of the village is a recent development of the jirga it was not so in the past… there are numerous problems like health … and developmental works cannot be overcome without the efforts of these elders with changing times there was therefore an increased potential that the jirga system might engage in local health issues thus taking on functions beyond dispute resolution participants described jirga membership as flexible depending on the issue at hand as a rule membership was aligned with status and wisdom the white bearded they are known people whom the people ask for jirgas people know well and he is a wellknown person and he is the one who attends every jirga people invite him to come for solving their problems whilst age is generally respected this does not preclude younger men from being invited to a jirga wisdom and strength are recognised and valued even a younger person can be the jirga elder … some of the men are strong wise … even some women are strong and others are weak like me… in our locality this woman is strong enough to talk issues with men… this highlights the potential for community engagement through the jirga around health issues whereby behaviour change needs to happen at household level nevertheless the status that comes with wealth and education are key factors in membership they look somehow for either the malik religious leader or white bearded or look for a rich person nobody brings a poor man … the poor is looked down upon decisions are mediated formalised and invariably respected denoting the influential impact of jirgas and the respect they command this is just as salient for jirgas that focus on health maintenance and disease prevention for example in relation to sanitation villagers get assembled and it is conveyed to them to … dig streams for getting new water clean the water channels and the dirt is … in our area it is such like that the residents of … get together and collect rs 100 or rs 150 from each home then the money is given to a worker who cleans the drain and throws away the dirt … the elders of the area get together about the sanitation management jirga members wives agreed with this general acknowledgement of respected influence and its potential to improve health behaviours all the females are of the opinion that the jirga can play significant role in health because the jirga members have strong position in the community they can mobilise the people for cleanliness campaign … they can also utilise community volunteers to create any type of effective awareness what emerged is that the most likely effective engagement channels are those that are built on levers of age gender and educationie the jirga works because it gathers men who are respected in the community on the basis of their status related to age wealth wisdom and education level because of the respect commanded by jirga decisions it became clear that only an intervention engaging jirga members would challenge deeply embedded cultural misconceptions about iodised salt figure 3 highlights the prominence of the jirga in the local communities discussion this research focussed on communication channels in local families the communities around them and highlighted the key influential role of the jirga linked both to the standing of its members and the community cohesion ethos that it embodies gendered decision makingprocesses within the household have been highlighted as restricting womens autonomy 24 whilst in one respect our data confirm this a more complex hierarchy of decisional power has been highlighted whereby the concept of wisdom an amalgamation of age experience and education presents important possibilities community members with the least autonomy are therefore the youngest uneducated females who rely on a web of socially and culturally determined ways to influence decisionmaking engaging jirga members in discussions about iodised salt was key in understanding barriers to use and designing an intervention that would activate the most influential levers to decision making in the community this resulted in a multicomponent awareness raising campaign that included the design and distribution of leaflets and posters in key venues the delivery of health education sessions to groups and individuals as well as the broadcast of an interview on local radio such a variety of engagement strategies attuned to the local community characteristics maximised the effectiveness of our intervention despite challenging structural conditions elmusharaf et al 24 highlight the limitations of strategies to improve the demand for health services in resourcelimited settings these include a lack of knowledge of the target community resulting in a lack of understanding of three fundamental influences on the decisionmaking environment gendered decision making norms multigenerational dialogue and appropriate communication to date the literature on the jirga has been descriptive failing to generate indepth understandings about how and why the model works 7822 within this particular sociocultural context the jirga exemplifies elements of what we would recognise as deliberative democracy and addresses some of the three limitations above 24 relatively few models of community engagement have sought to capitalise on such existing and culturally embedded mechanisms of communication and influence this paper sought to bring together these two research strands in order to develop a bespoke community engagement strategy around the use of iodised salt community engagement can of course vary during the lifetime of a project snijder et al 14 have recently developed a matrix of community engagement across the four stages of project development diagnosis of the issue development of appropriate strategies implementation of the intervention and evaluation for each stage they detail seven levels of community participation nonparticipation passive participation participation by information participation by consultation functional participation interactive participation and selfmobilisation their study builds in part on omaraeves et als 19 research which compares the effectiveness of four models of community engagement 1 when the health need is identified by the community and they mobilise themselves into action 2 where the need for an intervention is driven from outside of the community but community insiders are consulted over its development 3 where the need for an intervention is driven from outside of the community but community insiders collaborate over its development 4 where the community is involved in the delivery of the intervention only omaraeves et al 19 found the fourth mode of community engagement to be particularly effective and postulated that this might be linked to the expertise and credibility of empathy of the intervention deliverers our intervention adds to this framework by arguing that a sound understanding of community dynamics lines of influence and communication can only help tailor a community engagement approach hence we engaged with the jirga first and foremost in order to determine the focus of the intervention this was a combination of models 1 2 and 3 maximising the potential of these influential entry points into the community was key in ensuring the intervention success once the focus of the intervention was decided groups were consulted over the best ways to ensure effectiveness and local outreach workers delivered some of the intervention as did imams health care workers and shop keepers beyond this this intervention also built on long standing and trusting relationships between afpk workers and the local community strengths and weaknesses this research took part in a relatively small area in north west pakistan and the extent to which our findings can be translated to other parts of the world needs to be considered carefully the process undertaken does however have relevance for many other settings explicitly exploring naturally occurring channels of communication of influence in any community prior to setting up a health improvement intervention should help maximising its effectiveness potential conclusion this article provides an example of an intervention developed in a particularly challenging cultural and socioeconomic context in north west pakistan a variety of engagement strategies attuned to the local community characteristics maximised the effectiveness of our intervention despite challenging structural conditions whilst gendered decisionmaking processes are well acknowledged and in one respect our data confirm this a more complex hierarchy of decisional power has been highlighted the concept of wisdom an amalgamation of age experience and education presents important possibilities that should be maximised in future health improvement efforts referring back to snijder et als 14 matrix partly for pragmatic reasons linked to the distance between the uk and pakistanbased teams which limited the control that the ukbased team could exert and partly due to our moral intent the driving modus operandum throughout the project was one of interactive participation this process of maximisation of local cultural knowledge prior to and as part of a community engagement effort in order to understand the levers of influence and communication is one that has application well beyond the particular setting of our study abbreviations afpk abaseen foundation pakistan fgds focus group discussions uic urinary iodine concentration uk united kingdom competing interests the authors declare that they have no competing interests

background this paper describes the community engagement process undertaken to ascertain the focus development and implementation of an intervention to improve iodised salt consumption in rural communities in north west pakistan the jirga is a traditional informal structure which gathers men respected within their community and acts in a governing and decisionmaking capacity in the pukhtoon culture the jirga system had a dual purpose for the study to access men from the community to discuss the importance of iodised salt and as an engagement process for the intervention methods a number of qualitative data collection activities were undertaken with jirga members and their wives male and female outreach workers and two groups of women under and over 40 years old the aim of these was to highlight the communication channels and levers of influence on health behaviour which were multiple and complex and all needed to be taken into consideration in order to ensure successful and locally sensitive community engagement results communication channels are described within local families and the communities around them the key influential role of the jirga is highlighted as linked both to the standing of its members and the community cohesion ethos that it embodies engaging jirga members in discussions about iodised salt was key in designing an intervention that would activate the most influential levers to decision making in the community gendered decisionmaking processes within the household have been highlighted as restricting womens autonomy whilst in one respect our data confirm this a more complex hierarchy of decisional power has been highlighted whereby the concept of wisdoman amalgamation of age experience and educationpresents important possibilities community members with the least autonomy are the youngest uneducated females who rely on a web of socially and culturally determined ways to influence decisionmakingthe major lines of communication and influence in the local community described are placed within the wider literature on community engagement in health improvement the process of maximisation of local cultural knowledge as part of a community engagement effort is one that has application well beyond the particular setting of this study

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introduction although women in most parts of subsaharan africa and uganda in particular have a higher prevalence of hiv than men 12 men living with hiv are more likely to present late for care compared to women 3 4 5 the recent uganda population based hiv impact assessment reports that 296 of adults newly diagnosed with hiv had a cd4 count of less than 350 cellsμl slightly more than a third of these were men 2 fewer men seek testing and counselling services on a routine basis leading to late diagnosis in latestage disease progression 6 low perceptions or knowledge about hivaids and the benefits of voluntary counseling and testing services have been reported for mens negative attitudes to access hivaids services 7 the provision of information can improve individuals hivrelated health literacy 8 health literacy is required in making critical health decisions to manage individuals health including to seek and access appropriate health care 9 in addition mens supportive social relationships with the healthcare professionals their ease of access to the hiv care services and their ability to seek the services have been reported to determine their access to the services 10 due to late presentation men develop opportunistic infections with poor treatment outcomes 11 and high healthcare costs the costs of medical treatment such as the costs for standard blood viral load and cd4 tests prior to the initiation of treatment the treatment of opportunistic infections and administration have also been revealed to be barriers to the access of hiv care services among people living with hiv 10 12 13 14 this increases the risk of onward transmission due to uncontrolled viremia and lack of awareness of hiv status 15 early presentation for care is important for reducing the risk of mortality and improving quality of life among people with hiv 16 it can also reduce the risks of virological failure and loss to care 17 18 19 masculinity norms are social expectations about appropriate roles and behavior for men 20 these have been recognized as an important influence on mens health behaviours particularly in hiv care engagement serving as both barriers and facilitators 21 for example while some norms emerge as facilitators to care for men who believe antiretroviral treatment will allow them to reassume masculine roles and relationships these same norms serve as barriers to care for other men who fear that hiv will threaten their traditional roles as fathers and husbands 21 earlier studies conducted in central and rural eastern uganda among male fisher folk and those in the gold mining community respectively highlighted the influence of masculinity norms on mens engagement in hiv care 22 23 24 among fishermen and other male fisherfolk it was reported that the masculine roles of worker and provider husband and sexual partner and the appearance of physical strength were compromised by hiv but restored by arts positive effects on health yet occupational and structural factors specific to mens role as worker remained as barriers to engagement in hiv care 22 in an artisanal gold mining community mens fear to be or actually being judged as unable to work and being marginalized from work led many not to initiate hiv treatment or to drop out and this undermined their masculine repute as hard workers earners and providers for their families 23 lastly siu and colleagues report that mens treatment seeking behaviours corresponded with different masculine ideologies family and societal expectations to be a family provider and respectable role model encouraged treatment to regain and maintain health 24 however reputational concern with strength and the capacity for hard physical work income generation and sexual achievement discouraged uptake of hiv testing and treatment since it meant acknowledging weakness and an hiv patient identity 24 however these studies were conducted among specific subpopulations whose social context did not necessarily reflect that of men in the general population irrespective of type of occupation in addition masculinities vary and the experience of masculinity is not uniform across or within cultural contexts the central assertion here is that masculinity is dynamic and enacted and sustained through andor in different circumstances and as the society around a man changes through his lifetime hence it may vary according to the social groups of men that comprise a particular society 25 this study therefore aimed to explore how masculinity norms influence mens presentation for hiv care in eastern uganda theoretical framework masculine respectability and reputation this study conceptualized masculinity from wilsons concepts of respectability and reputation wilsons early ethnographic work suggests that these concepts inform two closely interconnected value systems by which men relate their position in society these value systems structure mens social relationships shape how their identities are produced maintained and challenged and govern their conduct within the community 26 wilson states that respectability is the degree of conformity to the ideals of the whole legal society by legal society he implied the moral values of institutions such as the family and church in which one could participate in an official capacity he argues that respectability accrued from andor was affirmed by proper attention to the requisites of marriage and providing for children consistent hard work and adequate material possessions such as a home economic independence and education as well as the ideals of the church therefore respectability was concerned largely with morality and membership of and active commitment to the wholeexternal society 26 on the other hand reputation is the honour accrued to a man as a result of his masculine activities according to wilson reputation was almost entirely shaped by the perception of male peers and was oriented towards proficiency in all male activities and roles including sexual prowess fathering many children gamesmanship skills including toughness and authoritydefying behaviour wilson contends that reputation reflects the congruence of how a man views himself and how he is viewed by other males wilsons respectabilityreputation model provided a relevant framework for interpreting mens considerations regarding presentation for hiv care materials and methods ethical considerations we obtained ethical approval from makerere university school of public health research and ethics committee we also obtained administrative authorization from the chief administrative officer district health officer of jinja district and the management of family hope centre all study participants either gave written informed consent or used a thumbprint before interviews study setting and design this study was conducted in jinja district eastern uganda between october and november 2020 uganda is ethnically diverse with over 30 different ethnic groups contained within its borders masculinity remains strongly tied to the breadwinner identity and ones role and way of participating in family and community life continues to be highly designated by ones sex men hold more power and status in both family and community spheres and are considered responsible for productive labor outside of the home in addition there exists one of the dominant masculine ideals of being a provider primarily embodied through responsible fatherhood jinja district is a patriarchal society in which men hold primary power and predominate in roles of political leadership moral authority social privilege and control of property it is also patrilineal meaning that property and title are inherited by the male lineage the district has a population of about 502815 people with an hiv prevalence estimated at 47 among adults aged 1564 years 2 in 2019 approximately more than half of adult men newly initiated on art in jinja presented late for care 27 the district has a number of hiv care sites that include 1 regional referral hospital 2 pnfp hospitals 5 health centre ivs 3 special hiv clinics 3 armed forces clinics and 14 health centre iiis this study was conducted in partnership with family hope centre a private health care facility in the district supported by the childrens aids fund uganda in this setting a qualitative descriptive analysis situated within a constructionist epistemology was employed in exploring the role of masculinity norms in mens late presentation for hiv care study population sampling and recruitment the study was conducted among two populations adult men living with hiv who presented late for care at family hope centre and hiv negative men and woman in selected communities participants were eligible if 1 were aged 18 years and above 2 working or spending most of ones time in the selected communities and 3 willing to talk about masculinity norms and hiv exclusive criteria was inability to speak lusoga or english and declining consent sampling and selection of study participants we purposively sampled all study participants adult men living with hiv who presented late for care at family hope centre were selected using the maximum variation strategy by including men of different age education level and marital status among others who had presented late for hiv care on the other hand hiv negative men and women in selected communities were selected using the homogenous sampling strategy by ensuring all participants in the same group are in the same age group and sex data collection procedures four research assistants fluent in both lusoga and english with experience in qualitative data collection methods were recruited and trained for data collection a structured form was used to capture the basic sociodemographic information of the participants in depth interviews among men living with hiv and focus group discussions among hiv negative men and women were also used to collect data on the role of masculinity norms on mens late presentation for hiv care before data collection two pilot fgds and one idi were conducted in a village neighbouring the study area to test the flow of the discussions and interviews and how long each would last data was then collected using the idi and fgd guides to explore the role of masculinity norms in mens late presentation for hiv care in jinja district these elicited information on the beliefs and what it means to be a man in jinja and how this negatively affects mens presentation for hiv care the study involved 20 idis and four fgds the recruitment of participants ceased when this did not result in additional perspectives or information idis were held either in lusoga or english depending on the participants preference and interviews lasted between 30 to 40 minutes each fgd had 910 members and conversations were held in lusoga and on average lasted one and a half hours discussions were guided by a trained moderator fluent in both english and lusoga a note taker also captured details of the fgds with permission from all study participants interviews and conversations were audiorecorded and recordings transferred to a computer and kept secure in google drive for subsequent analysis data management and analysis three transcribers fluent in lusoga and english transcribed the audio interviews verbatim and typed into microsoft word with direct translation into english in addition since recruited research assistants were fluent in both lusoga and english translated transcripts were distributed among them to ensure correct interpretations the field research team and investigators read through all the transcripts and notes then used open coding to derive codes from the text data and later developed categories and themes as indicated below fig 1 data analysis was done manually the analysis team comprised of three people and these collaborated by holding physical team meetings throughout the analysis process a weekbyweek plan for analysis was drafted and the plan included a reference to the data analysis phase and coding assignments for each team member during each iteration of coding team members coded the same two to three transcripts into the codebook during meetings each coded statement was compared across members of the analysis team disagreements were discussed until the group reached consensus much of the discussions revolved around the similarities differences connections and patterns within and between the codes the discussions revealed high levels of agreement between the team and a consensus was able to be reached about the data after all of the transcripts had been coded using consensus coding the team then met one final time to review the codebook during the meeting the codebook was developed into a thematic structure that comprised of categories and associated themes that described the role of masculinity norms in mens presentation for hiv care the themes were then reviewed and approved by all members of the analysis team data analysis was guided by the five steps of qualitative data analysis framework 28 these include familiarization with the data by reading through transcripts listening to the audios and going through the field notes identification of a thematic framework by making notes writing down recurrent themes and issues which emerge as important to study respondents indexing the data by applying the thematic framework to the individual transcripts grouping similar codes under the same themes and subthemes charting data through arranging appropriate thematic references in a summary of chart and mapping and interpretation of the data through which data were examined and interpreted 2829 procedures used to ensure trustworthiness of data and other processes investigators and research assistants had the required knowledge and skills to perform their roles as mentioned under data collection procedures two pilot fgds and one idi were conducted in a village neighbouring the study area to test the interview protocol investigators conducted regular debriefing sessions with research assistants and field notes were collected as referential materials during data analysis interviewers spent an average of 34 weeks to engage with study participants we used methods triangulation to test validity through the convergence of information from both idis and fgds we also used two purposive sampling techniques to make sure that the selected participants were representative of the variety of views of adult men living with hiv who present late for care and hiv negative community members across jinja results characteristics of study participants a total of 20 men participated in the indepth interviews with a mean age of 474 years majority were married 1520 and primary level holders 715 a total of 38 individuals participated in the fgds nineteen women participated in two womens fgds with a mean age of 295 years they were mainly housewives and businesswomen nineteen men also participated in two mens fgds with a mean age of 282 years they were mainly casual workers role of masculinity norms in mens late presentation for hiv care qualitative findings revealed three themes that highlighted the role of masculinity norms in mens late presentation for hiv care these included fear of loss of respect preservation of reputation and maintaining a sense of normality fear of loss of respect being shamed in almost all the idis and fgds mens fear of being shamed stigmatized and discriminated against by the community was mentioned as a reason for late presentation for hiv care an idi participant was quoted saying i feared that i will get ashamed thus did not start the medication there is also stigma and also discrimination in my community and i feared people to discriminate against me being marked as hiv positive participants mentioned that men feared to be seen at an art clinic as this would serve as an indication that they were hiv positive men think that the medication is like a belt tied on them for everyone to see they fear peoples perceptions of them and reactions once they are known to be positive in particular an idi participant mentioned that a man thinks being seen as an hiv patient would reduce his love in the village he also thinks that the people are going to see him as an hiv patient when he starts the treatment he would have reduced on love at the village and that is what most men fear losing a partner in some of the idis and fgds participants mentioned that mens fear of a spousepartner leaving was also a barrier to presenting early for hiv care inlaws of men living with hiv who were married often advise the wife to leave him before he dies this is to prevent the woman from becoming a widow since hiv was perceived to be fatal an idi participant reported to have hesitated presenting to hiv care for fear of his wife running away from home however he met a health worker who told him to bring the wife to the facility for counselling i was worried that the wife was going to run away there i got worried but i met a health worker called rogers who told me that you bring her the first problem is with the woman especially men fear their women they think she will leave if she gets to know losing a job both fgd and idi participants mentioned that men delayed to present to hiv care fearing that their bosses or coworkers would find out about their hiv status and make them lose their jobs it was reported that men are afraid of being labelled weak to engage in some work activities because they will end up being chased from work since they are no longer useful the nature of the jobs i do in that if they come to know they will say that i am weak so they dont want to give you hardships because i have witnessed many people who have been chased from work losing maledefining behaviors and traits idi participants stated that men delayed to present for hiv care for fear of giving up leisure activities like alcohol drinking smoking and making sexual advances which were a requirement for successful art treatment now there is someone who is being told that with this medicine you wont smoke you wont take alcohol but when cigarette and alcohol is what he knows as his life others because he is fearing that if they see me i will cease vibing girls participants pointed out that some men delayed to present for hiv care due to fear of art side effects it was mentioned that men feared to lose some of their traits like weakening due to the drug toxicity therefore unable to work andor result into failure to father children people say that when you go and start the medication some medicine stop men from producing that is why some people say that let me first produce before i go into treatment losing their social status it was mentioned that some men delay to start treatment because of fear of losing their social status a problem an average man would not have those in high positions find it hard to start hiv care because of being worried about people talking about them they are also worried that they will no longer be respected in society and anything they say will not be seen as relevant some because of their social statuses the average man wouldnt mind about what people talk about them those in high positions i think those in high positions are normally reluctant preservation of reputation tight work schedules fgd participants mentioned that men struggled to make time off work to report to the health facility for initiation main reasons were some because of the nature of the work whereby someone is expected to report early in the morning and leave late in the evening when health workers are no longer at work as narrated by a male participant in fgd the work we do you can have a job where you start work at 7 am and you will leave at 7pm so that means you have no time to go and get medication so i think that also causes a man not to get medication in time sometime a lot of work sometimes he says that i have a lot of work to do thus this also at times limits the man to go for treatment competing family roles it was also reported that mens role to care and provide for their families led men into neglecting their own health especially if their earnings werent adequate enough yet medication was known not to be for free because some people are there in the villages and they think that the medication is just sold that also scares them because they know they have to look for some money for feeding at home and then look for money for medication lack of responsibilities in one fgd it was reported that men who did not have any responsibilities for instance no family to look after were not motivated to start hiv care once they were diagnosed positive such men felt that they didnt have any value in the community and therefore no need to take drugs to prolong life you can be a man true but you do not have responsibility at home you say to yourself i have no people i am looking after at home and now i am positive in other words you will see yourself with no importance and you say to yourself why dont i die because there is no one that i am looking after maintaining a sense of normality fgd participants reported that the absence of hiv symptoms at the time of diagnosis made men feel like the situation was not yet serious to warrant treatment or that the diagnosis was a false one they added that some men first wait to experience body weakness and its only when they start seeing signs that guarantees being hiv positive its this that triggers them to wake up and start treatment at a later stage men who feel that they still have some energy think they will last without the treatment what i think is that someone can delay if they have taken long to see the signs but yet they know they are positive and they tested when they take long to see those signs they will say aah after all nothing shows i am negative let me move on i am fine thats when he doesnt have any sign on the body to show that he is sick so he will have that in mind that i think they didnt check well and will first stay at that with false hope so when those weaknesses you know there is that body weakness that is caused by the disease and if there are some signs and symptoms thats when he will wake up and sometimes may wake up when its a bit late discussion this crosssectional study assessed the role of masculinity norms in mens late presentation for hiv care key themes generated included fear of loss of respect preservation of reputation and maintaining a sense of normality this studys findings show that mens late presentation for hiv care in jinja district is greatly related to their concerns of loss of respect and the need to preserve their reputation and maintain a sense of normality in their families and society as proposed by wilsons respectabilityreputation theoretical model 26 one of the most noticeable findings of this study was the fear of losing masculine respectability which can be seen in most of the subthemes fear of being marked as hiv positive being shamed losing a job art side effects and losing a partner the fear of being marked hiv positive and shamed was due to the explanation that being seen presenting at an hiv treatment center was seen as something that undermines a mans dignity in society a study in dar es salaam tanzania 30 reported a similar finding where it was found that men avoid going to the treatment clinics because doing so would amount to making ones hiv status known since society expects men to be wiser and exercise selfcontrol in sexual decision making being seen at an hiv clinic is interpreted as a failure in the mans sense of judgment which undermines the respect and approval by others 24 different forms of stigma have been implicated as barriers to achieving the full potential of numerous clinical advances to improve health at the population level including art treatment as prevention 31 32 33 internalised stigma has been found to impact certain decisions like avoiding to seek care when needed 34 several studies have also shown an association between internal stigma and poor affective health and wellbeing as well as poor health care behaviors 3536 internalisedperceived hiv stigma encompasses feelings of being less than others dirty or unclean andor deserving of negative outcomes due to having hiv 36 a study in indonesia reported that participants individual moral judgement that associated their hiv status with amoral behaviours and engagement in sex with female sex workers and participants selfjudgement as dirty people or sinners which increased guilty feelings were additional factors leading to hivs perceived stigma 37 on the other hand enacted stigma which is the lived experience of discrimination against an hiv positive person through others actions or words is also known to have a negative impact on health outcomes 38 individuals have revealed having experienced hivrelated discrimination attitudes from healthcare professionals within healthcare settings for example in the indonesia study it was reported that clients were left untreated for many days in healthcare facilities 37 hiv stigma and discrimination by healthcare professionals traumatized the plhiv thus concealment of hiv status hindering access to healthcare services 373940 thereby influencing their health and wellbeing in the long run in this study men were also concerned about preserving their reputation by holding onto male defining behaviours such as alcohol drinking and smoking yet successful art treatment required that they give these up to men this meant losing a social life an explanation for this is that one of the most important social aspects of masculinity that majority of men living with hiv lose is the freedom to enjoy the male dominated social spaces to interact with their fellow men 24 the concern hindered their presentation for care early in the course of hiv infection in line with this finding some men reported avoiding or delaying the initiation of art or clinic attendance for fear of having to change male sanctioned risk behaviours including sexual risk in zimbabwe 41 and eastern uganda 42 and alcohol use in south africa 43 this studys findings also show that men presented late for hiv care as a way of maintaining a sense of normality and preserving their reputation in society it was reported that absence of hiv symptoms and still having strength at the time of diagnosis was one of the reasons for their late presentation to care a number of studies found a similar finding siu and colleagues found that enduring physical symptoms of hiv and delaying treatment for as long as possible was viewed as a sign of strength and courage among some ugandan miners 24 studies in botswana and uganda found that men in both rural and urban areas viewed seeking treatment as a sign of weakness 244144 and men avoided care in south africa because it made them feel vulnerable 45 this study adds to the growing body of research evidence that masculinity norms have a role in mens access and engagement in hiv care the generalizability of our findings is limited given the qualitative nature of the study as well as the use of purposive sampling to recruit participants in addition in depth interview questions were based on past experiences and this might have resulted in recall bias however this was minimized by including participants who had presented for hiv care in recent monthsyears conclusion findings show that the explanations for mens late presentation arise from the masculinity norms in that context these findings have some implications for public health interventions hiv programs that seek to encourage early hiv testing and treatment need to be more attentive to the values upheld my men associated with how their societies and cultures expect them to behave the attributes and responsibilities they should have to be considered as men in that context for example antiretroviral therapy could be promoted by emphasizing its value in rebuilding a mans respectability and role as head of family in regards to physical recovery supportive social spaces in which men can renegotiate masculinities that are more aligned to their presentation for hiv care need to be created and men need to be supported with livelihood projects because this can help them provide for their families and encourage them to maintain hiv treatment further research is also needed to understand how masculinity norms can serve as a facilitator to mens presentation for hiv care supporting information s1 file s2 file

in uganda adult men living with hiv are more likely to present late for care with a cd4 cell count below 350 cellsμl compared to women understanding why adult men present late for hiv care is important in improving early linkage to care studies across countries in subsaharan africa emphasize the role of masculinity norms defined as social expectations about appropriate roles and behavior for men in mens health behaviours particularly in hiv care engagement this study therefore explored how masculinity norms influence mens late presentation for hiv carethis was a qualitative study undertaken in jinja district eastern uganda between october and november 2020 we conducted 20 indepth interviews idis with men living with hiv who had presented late for care at family hope centre we also conducted four focus group discussions fgds with hiv negative men and women in selected communities of katende and walukuba conventional content analysis approach was used to identify themes across the collected dataa total of 20 men participated in the indepth interviews idis with majority being married 1520 75 and primary level holders 715 467 nineteen 19 women participated in two fgds with a mean age of 295 years nineteen 19 men also participated in other two fgds with a mean age of 282 years conventional content analysis results indicated that mens late presentation for hiv care in jinja district is greatly related to their concerns of loss of respect and the need to preserve their reputation and maintain a sense of normality in their families and society as proposed by wilsons 1969 respectabilityreputation theoretical model respectability was endorsed by the wider society while reputation was endorsed almost entirely by men and some women

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introduction an estimated 67 of the global health workforce are women but persistent gender challenges mean the promise of equal pay for equal work remains elusive 1 the world health organization advocates for the need to consider gender as a potential driver of social inequalities among human resources for health and therefore to systematically incorporate gender issues in health labour market analyses as a means to ensure the full effective and equitable participation of women and men in a high performing health workforce to meet current and future population health needs 2 traditionally gendered divisions of labour and social norms may lead to certain professions including femaledominated nursing and caregiving occupations being given lower social value and lower pay 3 4 5 6 income inequalities and other genderrelated problems have also been widely documented among women in traditionally maledominated health occupations such as medicine 4 7 8 9 it is increasingly recognized that health systems should be held accountable to sociocultural imbalances and establish equity benchmarks but gender considerations often remain neglected in health systems and health workforce research 10 11 12 in a landmark 2019 report the who identified four thematic areas with major gaps in the global hrh data and literature to support gender inclusiveness and equity occupational segregation gender pay gaps decent work and leadership 13 an example of such information deficiencies may include gender wage gaps experienced by the very professionals involved in the design and application of genderresponsive health policy differences in compensation for human capital endowments such as professional qualifications may help explain gender wage gaps nonetheless research persistently indicates simply being a women or employed in an occupation with skewed gender composition are major contributors to wage differentials 14 the causes of gender occupational segregation and wage gaps among hrh have been linked sociologically and psychologically to historical idealizations defined by and for professional men who were expected to be authoritative rational and committed to their jobs and earning more money women were typically seen as lacking such traits and thus less committed to employment and becoming professional leaders 35 despite social change and womens increased participation in higher education the influx of women into previously maledominated professions has not eliminated differential treatment by gender and may render some jobs less rewarding to men 359 in many countries traditional gendered hierarchies remain entrenched within health system institutional practices such that social biases continue to shape compensation policies professional development opportunities and productivity evaluations 41415 the result as argued by adams is that women tend to maintain their presence in historically femaledominated occupations some feminizing professions are internally devalued while many higherpaying professions continue to be maledominated 3 such gendered wage relativities may exacerbate hrh shortages if the health sector is perceived to offer less attractive career trajectories than other sectors 56 numerous observational studies have found significantly lower earnings for women health workers and feminizing health occupations within and across countries and over time in an international study of health worker wages from 21 countries boniol et al reported that women health workers earned 28 less than men on average after adjusting for key labour market variables a gap of 11 remained for women and men with similar occupations and working hours 1 a crossnational analysis of health workforce remuneration associated increasing shares of women participating in a given health occupation with a decrease in its wage rank 16 based on a timetrend analysis of sexdisaggregated survey data from 25 countries shannon et al suggested that the gender wage gap was widening with increasing feminization of the health labour market particularly in selected lowerand uppermiddleincome countries 17 in one highincome setting an analysis of administrative data from the canadian province of british columbia indicated significantly lower earnings among women physicians compared with men after adjusting for patient contacts and other factors 18 in iran rad et al found that women physicians salaries averaged 30 less than mens with 7 of the wage disparity remaining unexplained after controlling for speciality work experience and other measured confounders 19 a 19 unexplained component to the raw gender wage gap was found among health professionals in australia after decomposing gender differences in job characteristics and other human capital factors 14 from a crosssector comparative perspective the evidence is inconclusive as to whether the health sector is more unequal than nonhealth sectors in one analysis of data from five countries gender wage gaps were found to be less pronounced among science professionals than nursing professionals while the association was inconsistent in relation to education occupations 20 while wages are central to hrh recruitment and retention a lack of comprehensive wage information covering the broad scope of health occupations has constrained health workforce strengthening 16 studies on the gender wage gap typically focus on service providers however an estimated onethird of the global health workforce are composed of health management and support personnel that is those who do not provide direct patient care but are essential to the performance of health systems 21 this may include professionals with clinical backgrounds working outside the healthcare sector for example data on physicians in academic institutions in the united states have told of pervasive genderbased salary disparities among earlycareer and midcareer professionals even after adjustment for factors such as specialty and academic rank 2223 this wideranging category of hrh may also include individuals with nonclinical professional skills employed in the health system such as those whose core responsibilities involve health policy and programme research and development their labour market profile is much less known in canada women are overrepresented in health employment and continue to increase their shares in many professions requiring a university degree including family medicine and health policy research 24 we are unaware of any studies in canada explicitly addressing genderrelated wage gaps in the health policy research workforce to build the evidence base on wage conditions among health policy researchers this study investigates the gender composition and relative wages among health policy researchers in the canadian national context we address whether gender occupational segregation and wage gaps are issues within the health policy research workforce and compared with other nonhealth policy domains we use data from the 2016 canadian population census to assess and decompose wage disparities among policy researchers in health and other traditionally femaledominated sectors in relation to selected traditionally maledominated sectors econometric decomposition analysis is applied to estimate the explained portion of observed wage differences between women and men as well as any residual unexplained component the latter being commonly interpreted as a statistical measure of gender discrimination 51425 methods and materials study design and target population our data source was the canadian population census conducted quinquennially by statistics canada the census entails a complete enumeration of the population we used microdata from the 2016 mandatory longform questionnaire which was distributed to a 25 sample of all households and collected detailed sociodemographic and labour market information we limited the analysis to employed persons in the prime working ages of 25 to 54 years with a bachelors degree or higher educational attainment and who reported having earned wages or salaries in the year preceding the census the earnings data were captured from integrated administrative income tax and benefits records 26 the response rates for the 2016 census were 978 for the longform questionnaire overall and 971 for occupational earnings among longform respondents 2627 the health policy research workforce was identified according to the systematic taxonomy of the national occupational classification 28 this occupation is described as persons who specialize in research and analysis to support the development administration and assessment of government and nongovernment health policies programmes and standards as the main duties of their job these positions generally require a postsecondary degree in health science hospital administration social science or another related field managerial positions clinical service providers and academic researchers are excluded we also compared wages among health policy researchers with their counterparts in other socioeconomic and scientific domains as a tool for employment equity monitoring the noc structures occupations based on similarities in work duties responsibilities and requirements we evaluated a total of eight occupations within the minor group policy and programme researchers 28 this category includes policy research professionals in a variety of social legal community and government services given the similarities of skills and work usually performed as well as the overlapping educational routes for entering employment in these occupations wage structures are not generally expected to vary significantly in the absence of other structural or normative criteria such as gendered valuation analytical methods descriptive bivariate and multivariate analyses were conducted to assess and decompose gender differences in wages within and across the eight groups of policy researchers the outcome of interest was individuals annual gross wages and other employment remuneration as measured in canadian dollars the key predictor gender was captured as female or male we further considered a number of labour market variables widely postulated as influencing occupational earnings age educational attainment fulltime versus parttime work class of worker sector of work other social variables commonly regarded to intersect with gender were included in the analysis including designation as the primary household maintainer marital status child presence and adult migrant status the province or region of residence was also included to control for observed and unobserved influences on wage variance following a logtransformation of the wages variable to account for data skewness we employed simple linear regressions to assess the gender wage gap and then multiple linear regressions to assess the independent associations of gender and other labour market social and residential predictors on differences in occupational earnings we ran separate models for each occupation and then one pooled model including all eight occupations combined lastly we examined the difference in mean wages between men and women using the oaxacablinder decomposition method to recognize which average characteristics of men and women explained a portion of the wage gap and what was left unexplained 2930 widely applied in investigations of social inequalities in health and labour outcomes the unexplained component of the linear regressionbased decomposition is often attributed to discrimination ie a situation where persons with identical capacities and characteristics receive different benefits compared with others 2531 the analysis was conducted using the stata statistical software 32 the deidentified census microdata used in this study were accessed in the secure computing facilities of the statistics canada research data centre at the university of new brunswick personlevel bootstrapped sampling weights were applied to ensure population representation of the parameters and robust 95 confidence intervals population counts were rounded and all statistical outputs were subject to riskbased confidentiality vetting in respect of statistics canada data privacy protocols results descriptive analysis according to the 2016 census 122 510 canadians aged 2554 were employed in a policy research occupation with this workforce characterized as predominantly female specifically one in six were working in health policy research a domain characterized by more pronounced gender segregation of the eight policy research occupations under observation only the economics policy research workforce was maledominated the remaining occupations under observation tallied 5375 women all eight occupations were characterized with lower average annual earnings among women than men despite similarities in job duties and working conditions women in the health policy research workforce earned an average of 88 cents for every dollar earned by men across the other occupations the gender earnings ratio ranged from 72 to 91 cents to the dollar occupations in traditionally maledominated sectors tended to offer higher average levels of remuneration than occupations in traditionally femaledominated sectors the higherpaying occupations were also characterized with wider gender earnings ratios than their counterparts in traditionally femaledominated sectors across occupations having a higher share of women was correlated with lower mean wages among women the negative correlation of occupational feminization was even stronger in terms of dropping mean wages among men health policy researchers were primary employed in healthcare and social assistance establishments and in public administration although not exclusively so nonnegligible numbers were engaged in educational services and in other scientific and technical services conversely healthcare and social assistance establishments engaged large numbers of recreation policy researchers and social policy researchers in other words the boundaries of the health system were not easily delineated by any given policy research domain the age structure of the health policy research workforce differed little by gender in contrast women policy researchers in natural and applied science domains and in business development domains tended to be younger than men that is more often in the 2534 years age groupa reflection of the feminization of sectors where women have been traditionally underrepresented regarding other key labour market variables women health policy researchers were characterized less often than men with a graduatelevel qualification and more often in parttime work in terms of social identity variables women health policy researchers reported significantly less often than men as being the primary household maintainer yet more often residing in a household with children present women were also less likely than men to have been adult migrants to canada bivariate analysis of wage differentials by gender based on the simple linear regression model women health policy researchers were found to have earned 90 less than men this was the table 2 gender distribution and wage conditions among health and nonhealth policy researchers aged 2554 the gender earnings ratio refers to womens mean annual wage as a percentage of mens narrowest femalemale wage gap among the eight occupations under observation which otherwise ranged between 92 and 239 the bivariate analysis of the policy research workforce also confirmed a strong positive correlation between the degree of occupational feminization and the size of the gender wage gap multivariate and decomposition analyses of the gender wage gap the multivariable linear regression analysis upheld the evidence of a significant gender wage gap in the health policy research workforce with women earning 48 less than men after adjusting for other labour social and residential characteristics those in their early career stage tended to earn less than their more established colleagues all else being equal as did those who had immigrated to the country in adulthood compared with their counterparts who were nativeborn or who had migrated in childhood or adolescence across nonhealth policy research occupations the gender wage gap held as significant for five other domains womens earnings averaged from 40 less to 123 less than mens earnings no discernible genderbased wage gaps were found for policy researchers in government programmes and in education domains among whom any raw wages differentials were largely attributable to age graduatelevel educational attainment and adult migrant status in a regression model pooling all eight policy research domains together the seven femaledominated occupations were each found to pay significantly less on average than economics policy research all else being equal in particular the mean annual wage among health policy researchers was 211 lower than their counterparts in economics policy research in relation to economics policy researchers wages averaged from 154 less to 362 less the overall gender wage fig 1 mean annual wage by percent female among health and nonhealth policy researchers according to policy domain gap held as significant with the mean earnings of women assessed at 81 lower than men regardless of policy domain or other professional or personal characteristics the decomposition analysis indicated that as could be expected differences between women and men in educational attainment and other traditional human capital variables accounted for much of the gender wage gap in the policy research workforce however 15 of the wage differential was attributable to occupational differences ie by the domain of policy and programme research distinctly from other labour characteristics the gender wage gap was less pronounced in health policy research compared with the economics policy domain age differences between women and men accounted for 6 of the wage differential and differences in social identity characteristics accounted for 10 of the differential after decomposing gender differences in professional wages a significant 40 of the gap remained unexplained by the measured predictors discussion while several hrh studies have examined the persistence of wage differentials between women and men engaged in clinical services this inquiry represents the first nationally representative analysis in canada of gendered wage conditions among health policy researchers nonclinical professionals represent a large component of human resources in health systems and policy researchers play an integral role in the development and monitoring of equityenhancing government and community health policies and programmes as such managing gender disparities in health services delivery requires an understanding of underlying gender issues within the workforce itself tasked with policyactionable research echoing global hrh trends in gender composition the canadian health policy research workforce was enumerated as predominantly female perhaps not surprisingly we found evidence of a significant gender wage gap with women earning 48 less on average annually than men after adjusting for age education and other labour social and residential characteristics as examinations of health labour markets are enhanced when placed in a more comprehensive perspective that takes into account other sectors 20 we compared wages among health policy researchers with those for selected nonhealth policy research occupations disconcertingly in terms of the relative competitiveness of the health sector for attracting and retaining talent results from our pooled crossdomain linear regression presented significantly lower wages among health policy researchers than their counterparts in economics policy research the only maledominated occupation under observation these results were consistent with research evidence elsewhere of diminishing wage conditions with increasing shares of females in a given occupation such findings may express societal devaluation of womens work in the labour market and replicate and reinforce social perceptions of gendered differences in professional status even for similar types of work 36 14 15 16 moreover the crossdomain regression and oaxacablinder decomposition analyses showed of the femalemale wage differential of 81 in the total policy research workforce 40 remained unexplained by the measured predictors in other words womens earnings averaged around 32 less than mens due to unexplained factors an outcome that may be attributed at least in part to gender discrimination and other sociocultural and economic structures that hinder womens labour market opportunities significant adjusted wage gaps among healthcare workers have been reported across different national income contexts in studies using decomposition techniques to provide insight on the residual wage gap that cannot be accounted for by differences in womens and mens individual characteristics 61419 the unexplained residual of decomposed wage levels is widely postulated in the literature to capture effects of femalemale differences in societal conventions unconscious bias selfselection and other unmeasured processes leading to a systematic avoidable and unfair maldistribution of resources and benefits 6162531 it may however also denote some degree of estimation bias related to variables omitted from the operationalized model for example vecchio et al attributed a small part of the wage gap in australias health sector to gendered patterns of unpaid overtime 14 the lack of a question on expected hours of work in our data source precluded the ability to integrate this potential confounder the need for intersectoral collaboration and cooperation is accepted internationally as a critical principle for advancing population health and health equity goals 33 our analysis underscored that actions for health workforce strengthening and equity cannot be achieved within the health sector alone sectors are largely social constructs and calls for policy integration are increasing 33 alignment of labour market approaches should be considered necessary to improve and sustain the efficiency effectiveness and inclusiveness of work conditions among women and men with policy research expertise in the health sector and across interdependent sectors study strengths and limitations a number of data sources may potentially provide relevant information to support health labour market analyses each with their strengths and limitations 2 we used national population census data which offer the advantage of large sample sizes covering all labour fig 3 femalemale wage gap by percent female among health and nonhealth policy researchers according to policy domain sectors that can be disaggregated by sex and for specific occupations a limitation to this crosssectional source is possible selection bias from the inclusion of only those who were currently participating in the policy research workforce the analysis thus excluded those who may not have entered the paid labour market for parental or other caregiving reasons as well as those with previous policy research experience who may have ascended to higherpaying managerial occupationsboth of which may be gendered processes unlike many clinical professions the educational trajectory of health policy researchers can be diverse as such we were unable to identify within the available data those who may have acquired qualifications for employment in health policy research but were no longer in the labour force at the time of data capture we applied different techniques to analyse wage differentials from inclusion of a sex dummy variable in single regressions to flexible decomposition methods similarly to other hrh studies we did not correct for selectivity bias using complex maximum likelihood models that might potentially introduce greater uncertainty and heterogeneity to the population sample 14 our operational definition of the health policy research workforce may not have covered the gamut of personnel contributing to the development administration and evaluation of policies and programmes such as public health epidemiologists or academicbased scientistswho are grouped elsewhere in the canadian occupational classification with other professionals with similar skill levels and specializations that said the present ability to readily delineate health policy researchers as a statistical unit ensures crossdomain comparability with nonhealth policy researchers we thus anticipate this analysis may be reproduced and updated upon release of the 2021 national census microdata which were not available for research use at the time of this study crossnational comparative analyses of the health policy research workforce are still hampered by a lack of alignment in certain concepts with the international labour organizations international standard classification of occupations the latter structurally identifies some policy research occupations perhaps related to greater emphasis on transferability of skills there is no direct concordance by policy domain in particular the current isco version aggregates at the lowest level of classification all those charged with researching and analysing policy options among policy administration professionals 34 special attention is needed for mapping health policy researchers distinctly from the broader policy research landscape harmonizing labour force data based on the place of work would be inadequate as our results highlighted including only those working in health services establishments would miss more than half of all health policy researchers based on occupational descriptors conclusions like in many countries and at the international level canadas health policy dialogues are dominated by shortages and imbalances in the health workforce exacerbated by the covid19 pandemic it is increasingly argued reversing such trends requires investing in female health workers given that the health sector relies heavily on the recruitment and retention of women 35 the who has long recognized that the people working in planning and setting directions for health systems are indispensable but often overlooked in hrh data and discussions 21 addressing gender inequity and wage differentials across the health policy pipeline is one important element including among those tasked with bridging information from clinical and community health programmes to evidencebased advice for decisionmaking devaluation of womens contributions to the performance of health systems should be viewed as an ongoing crisis 9 although denial among researchers and the wider public of persistent gender inequality in the realm of work is widespread 5 as the present findings need to be tested in other settings this study aimed to pique interest and advance methodological considerations for more research on wage conditions in the health policy research workforce using an intersectoral and genderbased analysis lens authors information competing interests the authors declare they have no conflicts of interest • fast convenient online submission • thorough peer review by experienced researchers in your field • rapid publication on acceptance • support for research data including large and complex data types • gold open access which fosters wider collaboration and increased citations maximum visibility for your research over 100m website views per year • at bmc research is always in progress learn more biomedcentralcomsubmissions ready to submit your research ready to submit your research choose bmc and benefit from choose bmc and benefit from

background gendered challenges have been shown to persist among health practitioners in countries at all levels of development less is known about nonclinical professionals that is those who do not deliver services directly but are essential to health systems performance such as health policy researchers this national observational study examined gender occupational segregation and wage gaps in the canadian health policy research workforce using a crossdomain comparative labour market analysis approach methods sourcing data from the 2016 population census we applied linear regression and oaxacablinder decomposition techniques to assess wage differentials by sex traditional human capital measures eg age education place of work and social identity variables intersecting with gender household head childcare migrant status among health policy researchers aged 2554 we compared the gender composition and wage gap with seven nonhealth policy and programme domains as mapped under the national occupational classification by similarity in the types of work performedthe health policy research workforce n 19 955 was characterized by gender segregation 74 women compared with 58 women among nonhealth policy research occupations n 102 555 women health policy researchers earned on average 48 95 ci 1580 less than men after adjusting for other professional and personal variables this gap was wider than among education policy researchers with similar gender composition 75 women adjusted wage gap of 26 wages among health policy researchers were 211 95 ci 194228 lower than their counterparts in the maledominated economics policy domain all else being equal overall womens earnings averaged 32 lower than mens due to factors that remained unexplained by policy domain or other measured predictors conclusions this investigation found that the gender inequalities already widely seen among clinical practitioners are replicated among health policy researchers potentially hindering the competitiveness of the health sector for attracting and retaining talent our findings suggest intersectoral actions are necessary to tackle wage gaps and devaluation of femaledominated health professions accountability for gender equity in health must extend to the professionals tasked with conducting equityinformative health policy research

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abstract previous research suggests that asian american college students experience higher levels of pressure for academic success and higher levels of parental expectations and criticism compared to white americans moreover perceived discrepancies between parental expectations and academic outcome have been found to be related to psychological distress for asian americans in studies with white americans discrepancies between expectations and outcome have been specifically connected to worry a central feature of generalized anxiety disorder however worry remains an understudied psychological phenomenon in asian americans who may be particularly vulnerable to this form of distress the current study examines perceptions of living up to parental expectations and personal standards as possible mediators of the relationship between race and worry in a sample of 836 asian americans and 856 white americans results indicate that asian americans and white americans do not differ in levels of pathological worry as measured by the penn state worry questionnaire but asian americans report higher frequency of worry across multiple domains as measured by the worry domains questionnaire perceptions of living up to parental expectations of current academic performance and personal standards for preparation for a future career partially explain racial differences in frequency of worry about school standards for respect for the family partially explain racial differences in frequency of worry about the family the findings highlight the importance of considering personal and perceived parental expectations to understand asian americans worry iii to my ah ma chapter 1 introduction and literature review several years ago an independent ethnic media service pacific news service published an article in the san francisco chronicle entitled inside the asian pressure cooker this article suggested that asian american parenting and cultural practices are resulting in impossibly high expectations for children and that these expectations are leading to psychological distress and in extreme cases suicide among asian american adolescents and young adults other news outlets have highlighted similar concerns about the psychological costs asian american students pay because of the academic pressure placed on them by their parents for example in a 2009 article published in the san jose mercury news high grades high stress for asian american students in the bay area noguchi wrote many asian parents especially welleducated immigrants set skyhigh expectations for their children and while that drive to achieve has put asian students as a group at the top of the class its also forcing some uncomfortable conversations within the asian community about the damage those demands may cause a 2005 wall street journal article entitled new white flight similarly pointed to new immigrant parents particularly those from countries such as china and india who often put a lot of academic pressure on their children indictments of asian american parents of this severity coming from within and outside of asian american communities deserve empirical investigation psychological research is needed to better understand this phenomenon to provide valuable information for those serving asian american communities how might families serve as pressure cookers for asian american young adults for asian american young adults what are the psychosocial impacts of personal standards and parental expectations in particular life domains such as school or family do parental expectations differentially impact asian americans compared to white americans previous research on asian american young adults have suggested that they experience high levels of pressure for academic success high levels of parental expectations and criticism compared to white americans and that discrepancies between perceived parental expectations and perceived performance is related to anxiety and depression for asian americans indeed both popular media and ethnic minority psychology research have tended to focus on the impact of family and community pressures on asian american experiences of depression and related problems such as suicide risk however perceptions of parental expectations and criticisms have also been linked to worry a central feature of generalized anxiety disorder and other anxiety disorders experiences of worry among asian americans remain an understudied topic that may potentially involve a far greater number of asian american students than depression and suicide worry is a common and pervasive human experience in addition there is evidence to suggest that worry is a pervasive form of psychological distress for asian american college students previous research suggests that asian american college students exhibit high levels of worry across many domains such as the future finances and relationships the current study examines potential explanatory factors for racial differences between asian americans and white americans in experiences of worry asian american college students asian americans represent a heterogeneous group comprised of individuals with origins in east asia southeast asia and the indian subcontinent the 2000 us census recognized 25 distinct ethniccultural groups whereas twothirds of asian americans are immigrants to the united states the other third represent a diverse set of individuals ranging from those with immigrant parents to those whose families have lived in the united states for two centuries among asian american college students this diversity extends to other sociodemographic factors such as language proficiency income level and parents academic achievement as well as to psychological factors such as cultural orientation and the centrality of racial and ethnic identities although vast heterogeneity exists within the asian american college student population it is important to consider that there are also many similarities across different ethnic groups kim yang atkinson wolfe and hong found that different asian american ethnic groups share common cultural values of collectivism conformity to norms emotional selfcontrol family recognition through achievement filial piety and humility these cultural values suggest that family roles and academic achievement are important to many asian americans compared to white american parents asian american parents tend to place greater emphasis on their childrens academic achievement and filial piety social scientists have argued that asian americans especially immigrant asian americans perceive educational success as the primary pathway for social mobility in the us furthermore many asian americans perceive respecting and maintaining family roles as central to the preservation of their ethnic culture given the high investments and the threats associated with failure in the domains of school and family asian americans may be particularly vulnerable to experiencing worry in these areas theories of worry that account for how individuals process and respond to threats serve as a foundational basis for understanding worry among asian americans conceptual models of worry models of worry and generalized anxiety disorder in the general population focus on cognitive and motivational factors specifically models of worry emphasize four key contributors cognitive avoidance intolerance of uncertainty maladaptive worry beliefs and negative problem orientation borkovec and colleagues suggest that worry functions as a cognitive mechanism to avoid perceived threat and suppress negative emotional experiences when faced with perceived threat individuals with pathological worry engage in thought activity to reduce emotional and physiological distress referencing foa and kozaks model of emotional processing of fear borkovec et al argue that because worriers avoid rather than process emotional and physiological reactions to perceived threat this avoidance serves to maintain their anxiety dugas and colleagues propose that intolerance of uncertainty is central to worry intolerance of uncertainty is defined as an excessive tendency to perceive uncertain situations as unacceptable berenbaum bredemeier and thompson found that intolerance of uncertainty as measured by the intolerance of uncertainty scale is comprised of the following dimensions desire for predictability tendency to be paralyzed by uncertainty tendency to respond to uncertainty with distress and inflexible uncertainty beliefs intolerance of uncertainty has been shown to predict worry above and beyond intolerance of ambiguity perfectionism and perceived control several researchers have suggested that positive beliefs about worry contribute to the development and maintenance of worry these beliefs were summarized by borkovec hazlettstevens and diaz as follows worrying helps the individual figure out how to avoid or prevent bad events from happening worrying actually prevents bad events from happening worrying prevents future more emotionally evocative worrying worrying serves to prepare the individual for when bad events do happen worrying motivates the individual to get things done and worrying is an effective problemsolving strategy these maladaptive beliefs have been found to be shared across worriers regardless of their worry severity and whether they met criteria for gad although pathological worriers believe that worry is beneficial to them it actually serves to maintain their worry and the negative consequences associated with worry because as borkovec and colleagues have suggested it is a form of cognitive avoidance negative problem orientation described as a set of cognitiveaffective schemas that reflect how one views their problems in living is characterized by doubts about ones problemsolving ability perceptions of problems as threats to ones wellbeing and pessimism about problemsolving outcomes negative problem orientation is related to gad independent of anxiety and depression whereas the four factors described above are critical to our general understanding of worry and generalized anxiety disorder motivational interpersonal and cultural factors are also important to our understanding of worry and generalized anxiety as worry content tends to be focused on ones ability to successfully function in multiple life domains motivational contributors to worry higgins selfdiscrepancy theory suggests that anxiety is the affective consequence of discrepancies between particular domains of selfrepresentations specifically the actual self and the ought self higgins and his colleagues demonstrated the effect of this selfdiscrepancy in predicting anxiety with correlational studies priming studies and longitudinal studies higgins suggested that discrepancies between actual and ought representations of the self result in agitationrelated emotions because the person feels he or she is not living up to expectations or obligations of what he or she or significant others believe he or she should be doing and fears punishment higgins further hypothesized that individuals with actualought discrepancies may have had negative parental interactions in which their parents criticized or punished them for not fulfilling expectations in support of this idea stober and joormann and chang found a relationship between parental expectationscriticisms and worry higgins selfdiscrepancy theory posits that ought selfrepresentations are in fact internalized standards that motivate ones behavior two studies by berenbaum and colleagues provide insight as to how standards contribute to anxiety specifically worry berenbaum thompson and bredemeier found that the relationship between standards and worry is mediated by perceived costs that is to say having high standards leads to worry because one perceives the cost of failing to meet these standards threatening and a cause for worry a study by supinski and berenbaum suggests that it is not high standards in and of themselves but rather contextualized standards that are associated with worry for example hitting an eagle in golf may be a high standard for everyone but is a much higher contextualized standard for someone who plays golf as a hobby than for tiger woods an accomplished professional golfer in sum theories of worry have mainly focused on maladaptive cognitions and motivations although these factors have great explanatory and predictive power contextual factors can add to our understanding of worry because the models reviewed above as well as models that more broadly examine the influence of information processing on anxiety conceptualize worry as maladaptive responses to threatening stimuli evidence of crossethnic variations in the types and levels of threats and the types of coping strategies utilized in response to threats that provoke anxiety among asian americans suggests that asian americans may differ from other racial groups with regards to the contents of their worry and the frequency with which they worry in multiple domains for example interpersonal interactions may be more threatening for asian americans than they are for other ethnic groups chang showed that asian americans engage in greater problem avoidance and social avoidance strategies compared to white americans in addition chang found that asian americans engage in more negative problem orientation than white americans which dugas and colleagues have suggested is a strong predictor of worry severity in light of the evidence that anxiety among asian americans may also be driven by cultural factors it would be important to examine whether asian americans differ in their experiences of worry compared to members of other cultural groups and if so to examine what may account for such group differences experiences of worry for asian americans little research has been conducted examining rates of generalized anxiety disorder or other forms of anxiety among asian americans in fact clinical research on asian americans has focused specifically on social anxiety and not on generalized anxiety however a study by scott eng and heimberg found that asian american university students reported similar levels of pathological worry as students from other racialethnic groups but asian americans experience higher levels of worry across multiple domains than white americans and african americans these domains measured by the worry domains questionnaire were relationships lack of confidence aimless future work incompetence and financial scott and colleagues found that asian americans reported more worries than white americans in the aimless future domain though because of their small asian american subsample they were unable to determine whether the racial difference in worry frequency was statistically significant however the researchers interpreted these racial differences as being consistent with other data that suggested that asian american students focus on academic success more and fear academic failure to a greater extent than students from other racial groups it has been suggested that the pswq measures pathological worry and the wdq measures nonpathological worry other theorists have argued that both the pswq and wdq measure pathological worry but that the wdq is distinct from the pswq in that it also captures taskoriented constructive worrying a study by verkuil brost and thayer found that pswq predicts the perseverance of worry better than the wdq given that the two measures appear to cover distinct aspects of worry asian americanwhite american differences or similarities in these measures may point to racial and cultural differences in perfectionism coping styles and the function of worry as pathological or nonpathological potential influences on worry for asian americans due to their cultural and racialized experiences in the united states asian americans experiences with worry may be influenced by their perceptions of their parents expectations for academic achievement and maintenance of family roles and obligations chaos work on asian american parenting suggests that asian american parents are highly invested in their childrens academic success and personal maturity chao has suggested that chinese american parents and teachers use guan to ensure that children understand and meet parents and teachers standards and expectations in an interview study with chinese american immigrant mothers mothers reported being highly invested in their children several key themes were identified in their goals for their children fostering and maintaining a lifelong loving parentchild relationship ensuring that their children attend the best schools so that they can have future financialcareer success and honor their family instilling understanding of the importance of obedience to parents teaching respect and care for others fostering an easygoing and adaptive personality instilling good moral character and maintaining ethnic culture chaos research focuses specifically on chinese american parenting but research on korean american and indian american families suggest that parental investment in academic success and family roles is high among all three ethnic groups academiccareer achievement and family role obligations are particular important domains for asian americans in the study by scott et al the aimless future domain was the domain in which asian americans reported the most worry this finding is believed to reflect the high importance placed in academic and career achievement by asian americans which has been documented in numerous studies research on asian americans suggests that family role obligations are also of particular significance research by fuligni and colleagues suggest that east asian americans are highly invested in their role in the family and that they may have higher standards for their family role compared to white americans specifically east asian american high school students place higher value and expectations on their role in assisting supporting and respecting their family compared to their white american peers and this sense of family obligation increases after high school inman and tewari also documented the importance of family role obligations among asian indian americans to summarize further research is needed to understand asian americans experiences with worry much of the existing research on worry has focused primarily on white american populations but there is some evidence to suggest that asian americans worry more than white americans perceptions of living up to parental expectations and personal standards may explain possible racial differences in worry frequency between asian americans and white americans given the particular pressures placed upon asian americans in the domains of school and family chapter 2 hypotheses the current study tests the following specific hypotheses 1 congruent with past studies examining ethnicracial differences in worry asian americans will report higher frequency of worry in the domains of school and family measured compared to white americans but not differ from white americans in levels of pathological worry 2 for both asian americans and white americans their perceptions of living up to their parents expectations will be negatively related to pathological worry and worry frequency in domains of school and family 3 standards will be positively related to pathological worry and worry frequency in the domains of school and family for both asian american and white american groups 4 perceptions of living up to parental expectations will be higher for white americans than asian americans in the domains of school and family 5 standards will be higher for asian americans than white americans in the domains of school and family 6 standards and perceptions of living up to parental expectations will mediate racial differences in worry frequency in specific domains of school and family chapter 3 method participants and procedure a total of 1692 college students from university of california davis and university of illinois at urbanachampaign participated in the study the rationale for collecting data at these two sites is that though ucd and uiuc are similar in terms of being large public universities ucd has significantly more asian american undergraduates as compared to uiuc of the 1040 participants from ucds participant pool 1035 reported attending ucd 1 reported attending university of california santa cruz and 1 reported attending university of california berkeley during the regular academic year all of the 652 participants from the uiuc participant pool reported attending uiuc the mean age of the sample was 1925 years family socioeconomic status was assessed using the nampowersboyd occupational status scale 1 for the entire sample the mean oss score after taking the higher score for each individual participants parents was 7569 indicating middle class status 1 the nampowersboyd occupational status scale is based on educational and income of certain occupations from the 2000 us census scores range from 1 to 100 with 100 being the highest socioeconomic status level 100 on the oss correspond to the occupations of dentists physicians and surgeons and 1 on the oss correspond to the occupations of counter coffee shop cafeteria and dining room attendants and dishwashers the oss scores were coded by separate individuals and discrepant scores were recoded after group discussion examples of occupations that are scored a 75 or 76 on the oss are loan officer computer support specialist community or social service counselor and writerauthor the ucd sample reported lower parental occupational status than the uiuc sample t 639 p 001 there were differences between recruitment sites such that ucd had proportionately more women participants than the uiuc sample χ 2 1199 p 001 φ 2 08 the ucd sample was slightly older than the uiuc sample t 489 p 001 of the total sample 836 participants identified as asian american and 856 identified as white american table 1 displays the ethnicities and generational statuses of the participants ethnic background was not collected for white american participants participants were recruited through the psychology department subject pools at each data collection site participants completed the measures described below over the internet from a computer of their choice some researchers have suggested that internet surveys may be vulnerable to responder and sampling biases but others have found that such surveys are comparable to paperandpencil methods or even linked to higher response rates to sensitive questions and decreased socially desirable responding compared to paperandpencil methods participants were given course credit after completion of the study measures demographics questionnaire a demographics questionnaire was used to assess participants age ethnicity gender generation status parents occupations the pswq is a widely used 16item questionnaire designed to measure pathological worry sample items include my worries overwhelm me and ive been a worrier all my life in the present study internal consistency was high for the total sample for asian american participants for white american participants worry domains questionnaire the wdq is a 25item questionnaire designed to measure worry in particular content domains initial validation and subsequent studies using this measure demonstrated excellent psychometric properties the wdq measures worry in the following domains relationships lack of confidence aimless future work incompetence and financial an additional 5 items created by berenbaum thompson and bredemeier were added to tap into worry in the school domain an additional 7 items were created for this study to tap into worry in the family domains internal consistency was adequate for each subscale relationships lack of confidence aimless future work incompetence financial school and family the results described below focus primarily on the domains of school and family standards standards were assessed in the domains of academiccareer achievement and family role obligations participants were asked to rate to what extent they believe they should do each of the items listed standards for the domain of academiccareer achievement were adapted from the academic achievement subdomain of the living up to parental expectations inventory sample items from the wang and heppner scale include study hard to get a highpaying job in the future and perform better than others academically the original lpei had good psychometric properties for a sample of taiwanese college students standards for the domain of family role obligations were adapted from family obligations scale a 25item scale examining standards for assisting supporting and respecting the family sample items include help out around the house and treat your parents with great respect the original family obligations scale demonstrated good psychometric properties for multiracial high school and college samples perceptions of living up to parental expectations to assess for perceptions of living up to parental expectations participants were provided the same items as the standards measure but were instead asked to rate to what extent they believe they are meeting their parents expectations chapter 4 results tests for group differences to test for recruitment site gender and racial differences among the outcome variables i conducted a series of multivariate analyses of variance and estimated effect sizes with 95 confidence intervals table 2 displays the means standard deviations ranges for the ucd and uiuc subsamples and anovas of site differences no site differences were found between participants from uc davis and those from uiuc on any of the outcome measures therefore participants from both sites were combined in subsequent analyses there were gender differences such that women tended to report greater worry table 3 displays the means standard deviations ranges for the female and male subsamples and anovas and effect sizes of gender differences gender differences were found on the pswq and worry about school but not for worry about family subsequent analyses with worry about school as the outcome variable included gender as a covariate a significant gender x race interaction was found for pswq f 456 p 05 but not for worry about family or school as hypothesized asian americans reported significantly higher worry frequency in the domains of school and family as measured by the wdq but did not differ in terms of pathological worry as measured by the pswq also as hypothesized perceptions of living up to parental expectations in the domains of school and respect for the family were higher for white americans than for asian americans in addition the hypothesis that asian americans would report higher standards in the domains of school and family was supported table 4 displays the displays the means standard deviations ranges for the asian american and white american subsamples and ancovas and effect sizes of racial differences for the outcome variables and table 5 displays the displays the means standard deviations ranges for the asian american and white american subsamples and ancovas and effect sizes of racial differences for the predictor variables exploratory factor analysis of standards measure because the standards measure used in the present study was adapted from existing measures to tap into several proposed standards domains i conducted a principal components analysis with a varimax rotation to determine its factor structure using a traditional cutoff of 40 for the factor loadings five factors emerged which explained 6174 of the variance these factors mapped onto current academic performance standards standards for preparing for future career standards for living with the family in the future standards for respecting family and standards for spending time with the family the percentages of variance accounted for by these five factors were 32 89 1225 732 484 and 444 see table 6 for the items making up each factor and table 5 for the correlations between factors a principal components analysis yielded similar loadings on five factors for the perceptions of living up to parental expectations measure the reliability estimates for the perceptions of living up to parental expectations domain are as follows current academic performance preparing for future career living with the family in the future respecting family and spending time with the family the subscale of living with the family in the future was dropped in subsequent analyses because of its poor reliability estimates on the standards measure correlational analyses to examine the hypotheses that perceptions of living up to parental expectations is negatively related to worry and standards are positively related to worry controlling for gender i conducted correlations between the proposed predictors of worry and worry as measured by the pswq and the wdq in a previous study berenbaum thompson and bredemeier computed a composite worry score of standardized pswq and wdq scores because of the large correlation between these two measures however in the present study an examination of the difference between the magnitude of correlations for asian and white americans revealed that the associations between pswq and wdq were significantly weaker in the former compared with the latter ethnic group therefore a composite worry score from pswq and wdq scores was not computed further because some of the predictors in this study were focused in specific domains analyses to examine the predictors potential impacts on the worry the domains examined were conducted using individual wdq subscale scores rather than a composite wdq score results of the correlational analyses conducted separately for asian americans and white americans are displayed in table 5 i hypothesized that perceptions of living up to parental expectations would be negatively related to worry about school and family that is to say the more individuals perceive that they are living up to their parents expectations the less they will worry as table 5 shows for both asian americans and white americans perceptions of living up to parental expectations in these domains were not related to pathological worry this hypothesis was partially supported for worry associated with school and family specifically for asian americans perceptions of living up to parental expectations of current academic performance was modestly related to worry about school and family but perceptions of living up to parental expectations of preparation for future career respect for the family and family time were not related to worry about school or family for white americans perceptions of living up to parental expectations of current academic performance preparation for future career and respect for the family were all modestly negatively related to worry about school and family i hypothesized that standards about school and family would be related to worry for both asian americans and white americans standards about school and family were modestly correlated with pathological worry for both asian americans and white americans that is to say those with higher standards tended to endorse more pathological worry for both asian americans and white americans standards in the domains of school and family were also related to worry frequency in the school and family domains as measured by the wdq mediational analyses multiple mediation analyses were conducted to test the hypotheses that perceptions of living up to parental expectations and personal standards would mediate racial differences in worry frequency in the school and family domains as recommended by baron and kenny to establish mediation regression equations must be conducted to verify significant relationships between the independent variable and the mediator the independent and dependent variable and the mediator and dependent variable after controlling for the effects of the independent variable in addition to meeting these conditions a substantial reduction in the effect of the independent variable on the dependent variable must occur when the mediator is added i conducted two multiple mediation analyses to look at racial differences in worry about school and racial differences in worry about family i estimated direct and indirect effects of multiple mediators using the nonparametric bootstrapping procedure as recommended by preacher hayes this statistical method has several advantages it allows for multiple mediators to be tested simultaneously it allows for nonnormality of the sampling distribution it has higher power than traditional tests of mediation such as the sobel test and it reduces type i error because fewer inferential tests are needed analyses were conducted using the spss macros provided by preacher and hayes racial differences in worry about school in the first set of meditational analyses examining racial differences in worry about school worry about school was entered as the dependent variable race was entered as the independent variable and perceptions of living up to parental expectations for current academic performance perceptions of living up to parental expectations for preparing for future career personal standards for current academic performance and personal standards for preparing for future career were entered as potential mediators gender was entered as a control variable on the dependent variable the hypothesis that perceptions of living up to parental expectations and standards would explain racial differences in worry about school was supported results of the bootstrap tests showed that the total effect of racial group membership on worry about school was attenuated but remained significant when the mediators were included in the model the specific indirect effects of each proposed mediator showed that living up to parental expectations for current academic performance with a point estimate of 85 and 99 biascorrected accelerated ci of 121 55 and standards for preparation for future career with a point estimate of 15 and 99 bca ci of 35 01 were all unique mediators whereas perceptions of living up to parental expectations for future career with a point estimate of 02 and 99 bca ci of 12 09 and standards for current academic performance with a point estimate of 0019 and 99 bca ci of 080 10 did not add to the overall model in sum the bootstrap analyses indicate that perceptions of living up to parental expectations for current academic performance and standards for preparing for a future career partially mediate the link between racial group membership and worry about school race and gender continued to play a statistically significant role on the dependent variable even with the mediators in the model racial differences in worry about family in the multiple meditational analyses examining racial differences in worry about family worry about family was entered as the dependent variable race was entered as the independent variable and perceptions of living up to parental expectations for family respect perceptions of living up to parental expectations for spending time with family personal standards for family respect and personal standards for spending time with family were entered as potential mediators gender was entered as a control variable on the dependent variable my hypothesis that perceptions of living up to parental expectations and standards would explain racial differences in worry about family was supported results of the bootstrap test showed that the total effect of racial group membership on worry about school was attenuated but remained significant when the mediators were included in the model the specific indirect effects of each proposed mediator showed that only standards for respecting the family with a point estimate of 80 and 99 bca ci of 120 54 was a unique mediator whereas perceptions of living up to parental expectations for respecting the family with a point estimate of 18 and 99 bca ci of 38 02 perceptions of living up to parental expectations for spending time with family with a point estimate of 01 and 99 bca ci of 11 04 and standards for family time with a point estimate of 04 and 99 bca ci of 22 11 did not add to the overall model in sum the bootstrap analyses indicate that standards for respecting the family partially mediate the link between racial group membership and worry about school race and gender continued to play a statistically significant role on the dependent variable even with the mediators in the model chapter 5 discussion the results of the present study add to existing literature on racialcultural variations in the experiences of worry between asian americans and white americans this research indicates that asian americans do not differ from white americans in terms of severity of pathological worry but point to the specific domains of school and family in which asian americans worry more than white americans the results of this study suggest that two factors account for racial differences in worry frequency in these specific domains personal standards and perceptions of living up to parental expectations the findings that asian american and white american college students do not differ in terms of selfreported pathological worry but that asian americans report higher frequency of worry across multiple domains compared to white americans are consistent with previous results examining racial differences in worry in a previous study with a smaller sample utilizing similar measures of worry scott et al found no significant differences in pathological worry but higher frequency of worry among asian americans compared to white americans however because of their small asian american subsample scott et al were unable to determine whether the racial difference in worry frequency was statistically significant in the present study effect size and confidence interval estimates in the medium range suggest that these racial differences are robust of note asian americans reported higher frequency of worry in domains related to family and schooltwo areas of particular importance to asian american young adults given their age and racialethniccultural and immigrant backgrounds asian american students report greater fear of academic failure compared to other groups this may be reflective of a high cost allornothing mentality about education and other limited paths to social and economic success for asian americans asian americans emphasis on and concern for family have been noted in the work of various scholars for example a qualitative study conducted by pyke on korean americans and vietnamese americans found that these asian americans perceived themselves to be concerned about and committed to the care of their families more so than white americans concern about and commitment to school and family for asian americans were also reflected in racial differences in personal standards and perceptions of living up to parental expectations for asian americans compared with white americans consistent with hypotheses asian americans reported that they felt they were not living up to their parents expectations as much as did the white americans in the domains of family and school this finding is consistent with a study conducted by chang who found that among 89 asian american and 96 white american college students asian americans reported significantly higher parental expectations the finding that asian americans reported higher standards regarding respect for family but not school is somewhat surprising despite previous research indicating that asian americans place greater emphasis on academics than white americans the two groups in this study did not differ in their standards for school it is possible that this is reflective of the prestigious and competitive nature of both recruitment sites and that expected racial differences in school standards suggested in previous work may be found in more academically diverse samples what these results indicate is that perceptions of living up to parental expectations and personal standards are domainspecific and vary depending on a persons environmental and racialcultural contexts as hypothesized personal standards and perceptions of living up to parental expectations partially mediated racial differences in worry frequency in the domain of respect for the family perception of living up to parental expectations also partially mediated racial differences in frequency of worry about school these findings support higgins selfdiscrepancy theory and suggest that asian americans worry more compared to white americans because they have high standards and low perceptions that they are meeting their parents expectations only partial mediation was established indicating that other factors contribute to racial differences in frequency of worry about school and family for example intolerance of uncertainty negative problem orientation and maladaptive beliefs about worry all found to predict pathological worry may play roles in explaining racial differences perfectionism and coping styles are other potential contributors to these racial differences that asian americans and white americans differ in worry frequency but not pathological worry sparks several measurement and theoretical issues despite past research showing a strong relationship between the pswq a measure of pathological worry and the wdq a measure of nonpathological worry this study failed to demonstrate such a relationship among asian americans this finding may be an indication that the measures used are more valid for asian americans than for white americans given that these measures are designed to capture different types of worrypathological and nonpathological and as such are not expected to be highly correlated given that the wdq does not define worry the construct is open to participants interpretation it may be the case that as a group asian americans are interpreting worry on the wdq as less pathological than are white americans this finding also suggests that the nature of worry for asian americans may not be as is typically conceptualized pathological that is to say worry may be an adaptive and culturally appropriate strategy for managing stress and anxiety for asian americans norem s concept of defensive pessimism suggests that individuals may manage their anxieties about failure by being pessimistic while worrying and that defensive pessimism can be adaptive in the long term by motivating individuals to set goals and problem solve to meet those goals the application of norems work for asian americans has empirical support through a study by chang who found that asian americans tend to be more pessimistic than white americans and that pessimism is correlated with problemsolving strategies norem argues that defensive pessimism may be appropriate in cultures that value selfcriticism over selfpromotion such as asian and asian american cultures several limitations should be noted as they provide caution for interpretations of the findings and suggest opportunities for further research the present study was conducted with an academically homogenous group of highachieving undergraduate students the impact of perceptions of living up to parental expectations and personal standards on worry frequency in the domains of school and family may be substantially different with other asian americans and white americans this study focused on two specific domains of worry for asian americans and white americans further research is needed to explore other specific domains of worry for both asian americans and white americans conducting further studies examining worry with older asian americans will also prove valuable as several studies have suggested that asian american adults are less prone to worry and other types of anxiety than their white american counterparts the studys conclusions would be strengthened were there an acculturation measure as it is possible that orientations to asian ethnic or american cultures moderate the impact of perceptions of living up to parental expectations and personal standards on worry frequency the reliance on selfreport measures may obscure the negotiation parents and their collegeage children must play in generating and meeting expectations for the family school and other important domains future research would benefit from examining the reciprocal and dynamic nature of negotiating expectations longitudinally and using multiple informants finally this study points to potentially differential functions of worry for white americans than for white americans future research is needed to understand what are those functions the results of the present study have several implications for the treatment of worry among asian americans clinicians working with asian americans who report frequent worries must assess their clients impairment in functioning due to worry as worry frequency alone does not imply dysfunction this study suggests that efforts to reduce worry among asian american college students must target their and their parents expectations there is growing support for clinical efficacy of acceptancebased therapies considered the third wave of cognitive and behavioral therapies in the treatment of anxiety and depression hall hong zane and meyer suggest that acceptancebased therapies show promise for application to asian americans given their easternbased roots and at the same may still need to be adapted for this study was the first to demonstrate that perceptions of living up to parental expectations and standards account for racial differences in worry about family and school between asian americans and white americans specifically asian americans reported feeling that they were living up to parental expectations to a lesser degree than white americans at the same time asian americans tended to report higher standards for preparing for a future career and for respecting and spending time with their family the current study suggests that asian american college students may be setting high standards for themselves with regards to how they must respect and support their families and concurrently or as a consequence worry frequently about their families in addition asian americans worry about school may be partly a result of their perceptions of not living up to their parents expectations for their current academic performance as well as their own standards for how they must prepare for a future career however the finding that these high standards combined with feeling that they are not quite living up to parental expectations and with more frequent worries did not necessarily translate into more pathological forms of worrying for asian americans these patterns of findings suggest that worrying may serve differential functions for asian americans than for white americans and that worrying about family and school may be a normal and perhaps beneficial coping strategy for asian americans compared to white americans this study points to the importance of examining how individuals personal standards and the internalization of parental expectations influence cognitive processes of worry tables and figures

chan and the asian american center on disparities research for assisting me with data collection thanks also to the uiuc undergraduate research assistants who helped me with this project to the members of the culture emotion lab at uiuc past and present i will always appreciate our fifth floor wing of brainstorming and afternoon chai thanks to my grandmother siok kee tay and my aunt winnie saw chen for instilling the belief in me that saw women are smart strong and capable to my parents thank you for your unending support and constant encouragement to my husband siao you are a continual source of inspiration to me your love of science and drive to excel propel me to strive for greater things v table of contents chapter 1 introduction and literature review

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searching process the search strategy was broad and comprehensive combining a primary search with purposive searches in order to capture the most relevant evidence to support or refute the ideas around the four theory areas for the primary search a list of search terms was created from the theory development work selection and appraisal of documents consistent with realist review standards the test for inclusion was if the evidence was good and relevant enough to be included as this test is potentially lacking in specificity we developed a set of constructs within the data extraction form good enough was deconstructed as the quality of evidence expressed through fidelity trustworthiness and value and relevance related to the contribution of the evidence to the theory areas data extraction analysis and synthesis process theory development refinement and testing were iterative processes made visible through bespoke data extraction forms we undertook an abductive and retroductive analysis of evidence across data tables to look for emerging demiregularities this process was facilitated by the development of a set of plausible hypotheses if then statements about what might work for whom how why and in what circumstances about workforce development interventions for the support care workforce the data in the plausible hypotheses evidence tables were then used as the basis for further deliberations about the emerging contingencies across the evidence base which resulted in the uncovering of contextmechanismoutcome configurations an evidencebased narrative was developed to underpin under each configuration to further test and enhance the trustworthiness of the resultant cmo configurations and to facilitate the development of the final cmo narrative we conducted 10 semistructured audiorecorded interviews with stakeholders results the review process resulted in eight cmo configurations these are explanations that cumulatively constitute a programme theory about what works in workforce development for the older persons support workforce making it real to the work of the support worker if intervention design and delivery is close to the work of the support worker this prompts resonance with individuals participating in it which can result in cognitive and practice changes in them paying attention to the individual if workforce design and delivery pays attention to the individual support workers personal starting points and expectations of the role this prompts better engagement with the intervention paying attention to the individual within workforce development can promote positive personal cognitive and instrumental impacts and potentially impacts for the organisation tapping into support workers motivations if workforce development opportunities include elements of incentivisation then it is likely that participants will feel recognised and rewarded the relationship between incentivisation and having a stake in workforce development can lead to greater emotional and practical participation and engagement with the intervention joining things up around workforce development if interventions are developed in the context of an organisations goals including their human resource and quality improvement strategies this prompts alignment between the aims of the intervention and the goals of the organisation such that they mutually reinforce each other this leads to more sustained and lasting impact of the intervention reducing turnover and supporting the organisations retention strategy codesign if the right mix of people are engaged in the design of workforce development programmesinterventions this prompts codesign and a collective view about what needs to be done which can lead to workforce development that is more credible meaningful and relevant for the support worker with greater potential for positive outcomes for practice journeying together if the right mix of people are engaged in delivering workforce development programmesinterventions this can prompt learning together which leads to stronger cohesion across groups greater understanding of others roles and less duplication and impacts on residents perceptions of care taking a planned approach in workforce development if workforce development draws on theory or there is evidence of a planned approach this prompts the adoption of a systematic process in its design and delivery which leads to greater potential to demonstrate impact and learn about workforce development effectiveness spreading the impacts of workforce development across organisations if workforce development interventions are comprehensive in that they are multilayered and reflect broader developments relevant to the support workforce then this prompts attention on the way in which components of interventions reinforce one another increasing the potential for impacts to embed and spread across organisations conclusions cumulatively our eight cmo configurations provide a programme theory or contingent explanation which is grounded in evidence from the literature and in stakeholder perspectives about how workforce development works in improving outcomes for support workers organisations and older people the resulting explanatory framework draws together the key features of the cmo configurations and the relationships between them into a theoretical and potentially practical heuristic the framework represents the starting point or local context mechanisms and potential impacts of workforce development for support workers although the theory is specific to our synthesis context of workforce development we believe that the cmo explanations are sufficiently abstract to be transferable across most workforce development approaches the programme theory framework we have developed could be used to guide support worker workforce development initiativesprogrammes in the future pointing to what should be paid attention to and what might work that is it provides a plausible and credible account of what works how why and in what circumstances implications for practice the following implications for the practice of designing and delivering older persons support workforce development interventions are directly related to the eight cmo configurations of the programme theory 1 workforce development programmes should be organised to reflect the realities of the support worker role in a number of ways for example i inclusion of material and examples drawn from the reality of practice ii integrating learning within the expectations and boundaries of the role that support workers have iii bringing learning into the workplace on a sessional or integrated basis this may be more or less relevant depending on the need to access expertise to support learning the availability of a conducive learning environment and whether taking the workforce out of the service context may be desirable or necessary to address specific development needs andor to work together with people in different contexts 2 workforce development should be constructed to build on the life skills and experiences that individuals bring to the support worker role and enable role development and career progression for the individual and their organisation 3 workforce development should incorporate strategies and techniques that might incentivise and motivate individual engagement in workforce development these strategies and techniques should be designed to address both extrinsic and intrinsic motivators when possible to sustain motivation extrinsic motivators should address explicit criteria for goal attainment for example rewarding the achievement of specific changes to practice 4 there should be a systematic approach to the design of workforce development that is aligned with organisational strategy around for example priorities such as quality and integration across health and social care when this alignment is evident it should be possible to realise more sustained improvements in workforce knowledge and skills 5 designing workforce development interventions should include the involvement of the right stakeholders from the beginning of the development process stakeholders will probably include relevant agencies for example organisationsinstitutions that can provide specialist input andor educational accreditationcredibility and individuals for example support care workers patients residents and carers codesign processes should recognise and incorporate the views expertise and values of each stakeholder constituency 6 the delivery of workforce development interventions should include opportunities to involve others beyond the support worker themselves there will be learning and development issues for example improving team work supporting individuals transfer of care dignity in dementia and relationships between staff and families for which it would be relevant and resonant to learn among peers and recipients of care 1 the synthesis demonstrated generally poor reporting of workforce development interventions therefore in future research we recommend that i the typology proposed in this synthesis could be used to describe the nature of the intended workforce development ii authors provide clear and detailed description of the component of the intervention iii the theory of change for the workforce development intervention is clearly reported 2 what is the right mix of workforce and organisational related policy to deliver a sustainable support workforce for older peoples services what are the components of a fully integrated workforce planning and development strategy 3 how can the sustainability of workforce development be addressed in the challenging context of the older persons support workforce 4 what are the features of a wholesystem approach to workforce development operating within a specific geographical context and which pays attention to social and other characteristics 5 what approaches to the design and delivery of workforce development might be more effective in engaging hardtoreach groups within the older persons support workforce 6 what are the most effective ways to engage and integrate different stakeholder perspectives including those of patient and public representatives in the design and delivery of workforce development that enables support workers to addresses the needs older people 7 what interventions can accelerate support workers implementation of gains in knowledge and skill into routine service delivery 8 what are the best ways of including incentives in workforce development programmes that build on the motivations and aspirations of individual support workers chapter 1 introduction older peoples care context the uks population is getting older it is estimated that by 2031 one in five people will be over 65 years old 1 in the uk older people account for approximately 16 of the population throughout england and wales with 147 of over65s residing in northern ireland and 20 living in scotland 2 research suggests that older people require care that encompasses both health and social care functions 34 these needs require access to a wide range of generalist and specialist services including from statutory independent and voluntary services 5 older people are the main recipients of care in the nhs and thus care costs are relatively higher than those for workingage people 6 the provision of health and social care for older people may be more complex because of existing conditions for example it is estimated that 40 of people in hospital care over the age of 65 years have dementia 7 a series of recent investigations and highprofile cases have questioned current practices in services provided to older people both francis inquiries were focused on older peoples care 8 the care quality commission 9 identified concerns over the skills training and availability of the care workforce within hospital settings to deliver dignified and appropriate care and followed on from several other critical reports of the standards of care offered to older patients within the nhs in particular the parliamentary and health service ombudsman 10 called for standards of nhs care for older people to be improved health service journalserco 8 reference a range of recent publications in which concerns about older peoples inpatient care have been highlighted including those from the joint committee on human rights 11 age uknhs confederation 12 and the office for national statistics 13 furthermore the preferences and experiences of older people may not always be reflected in care policies structures and practices 1415 the rapid increase in the olderperson population is driving current pressures to develop new service models processes roles and expertise for delivering effective and efficient care especially when people have distinctive and often individualised care needs monetary investment in joint funding between the nhs and social care can support preventative care in older peoples services for example falls prevention and reduced social isolation and improve discharge pathways 16 the nhs is increasingly moving to multisectorial services which are integrated around the patient 17 which should promote models of care for the future which prioritise social and medical needs and should be relationship based 18 however integration has been in danger of being reduced to political rhetoric 19 owing to a lack of joinedup integration across services 20 and fragmented commissioning structures 21 the personalisation agenda whereby people fund their own care direct payments and personal budgets will lead to changes in the workforce in the future with more emphasis on personal assistants and social enterprises 22 as part of these changes greater use and development of the support workforce in health and social care is likely to remain a longterm priority for nhs managers and other sector organisations highquality care provision for older people is a strategic priority public policy interest in the support workforce has heightened recently as policymakers have faced a litany of care delivery failures 23 faced with an ageing population escalating levels of complexity and need in nhs and social care services and changes in workforce design the demands on the support workforce will most likely increase in the future 24 introduction nihr journals library policy context for support workforce development the use and role development of the support workforce has been somewhat ad hoc 43 and largely dependent on the various activities they perform 31 in the nhs policy context the importance of hca roles has not been underestimated but the discourse about them has at times been ambiguous 46 the literature reflects a general lack of clarity about the role of support workers 47 with roles developing organically rather than systematically and consequently their preparation and continuing development has tended to be haphazard 40 probably the most significant review to emerge in the uk recent years relating to the support workforce is the cavendish review 26 in response to the francis inquiry cavendish undertook an independent inquiry of the support workforce to ensure that all patients would be treated with care and compassion 48 based on the recommendations of the cavendish report a new certificate is now under development which will need to be completed in order to allow new hcas and support workers to work unsupervised in care settings 48 the care certificate is equally applied to the support workforce across health and social care replacing the national minimum training standards and common induction standards and reflecting the 6 cs 49 in addition in the uk a group of recent publications 426 50 51 52 53 have made recommendations for training for nursing assistants and hcas these reports have steered the commissioning of the shape of caring review 49 in nhs care talent for care has seen the development of a national strategy for all support roles in the agenda for change pay bands 14 the talent for care consultation in 2014 found universal support across the uk for a national strategic framework to develop the support workforce 2750 underpinned by the department of health 50 which directed health education england to improve the training and development for the support workforce however although a number of publications point to the need to improve the skills and training approaches currently used to develop support workers 9 education training and development for the support workforce remain challenging 33 further there are other challenges for the support workforce including career pathways role substitution regulation and retention described as follows career pathways one of the recommendations from cavendish 26 was to strengthen the care career trajectory for the support workforce and there is evidence that a number of healthcare support workers aspire to develop their careers 40 in social care there is acknowledgement of the benefits of career pathways for support workers but the picture is mixed 30 it seems that currently the degree of synergy between workforce development and opportunities for job and role development is not always clear leadership supervision and support should be developed in order to get the best out of people 2648 role substitution support workers have been traditionally represented as lowcost labour source 23 in recent times the division of labour in hospital care has led to delegation of nursing tasks to care assistant roles 54 traditional workforce boundaries have altered drastically with the support workforce taking on tasks previously undertaken by registered staff 3138 although the growth in the support workforce has sometimes been driven by initiatives to reduce costs involving role substitution for registered staff there is a degree of evidence to show that support workers can act as an additional resource to enhance older peoples experiences by improving the contact with care practitioners 3544 in social care there is role overlap between support worker and professional roles 30 when the support worker role is perceived as a substitute for professional nurse tasks 46 this can potentially compromise morale regulation regulation for healthcare support workers has been debated at length in recent years but as yet remains unresolved 46 in the uk a major review of health support workers commissioned in 1999 examined health support workers roles and regulation 55 core competencies in scotland were introduced in 2001 which informed further work about regulation for healthcare support workers 56 the current ambiguity about regulation means that there is little control over employment responsibilities education competence title and pay 38 in social care registration of homecare support workers has been recommended 57 with codes of conduct developed for health and social care workers 5859 in addition to governance frameworks 60 retention consistent employment patterns for clinical healthcare support workers have been reported 40 however in social care retention in home care is problematic with one of the highest staff turnover rates at around 21 twice the national average 61 securing new support staff and retaining those who are already employed in home care should be key priorities 59 for joint working staff retention is important as it has been reported that frequent staff turnover can have consequences for the numbers of staff who champion integration 16 recommendations have been made for employers to be supported to test care values at recruitment stage 26 however in home care high turnover demand and low pay can compromise valuesbased recruitment 61 workforce development interventions for this review workforce development interventions are defined as the support required to equip those providing care to older people with the right skills knowledge and behaviours to deliver safe and highquality services 22 evidence about interventions to develop the health and social care support workforce in older peoples care and services is limited and there have been calls for evidence to inform services about how to improve standards for the future 40 this is especially timely in the light of the introduction of new service models for example training for staff in integrated services whereby the workforce is expected to work in different organisations and across traditional boundaries 16 however there is scant evidence to show how approaches to training and education can link with impacts for the people who are the users of services 16 in social care evaluations have already concluded that national vocational qualifications are inadequate and that there is a lack of clarity regarding training 30 for the design and delivery of workforce development current provision is inconsistent 27 access to good developmental opportunities sits alongside variation in mandatory training and induction 26 nhs trusts and other services have adopted different approaches to workforce design and development models which confounds attempts to show a universal picture across health and social care recommendations included the need to shift to more workbased approaches to learning and development for all staff including the support workforce 63 in social care lack of attention to developing skills for support workers to implement personcentred care planning has been noted 30 in scotland recommendations about consultation with stakeholders in the design of workforce training study skills and support systems were made to improve support workers education and training 40 introduction nihr journals library summary calls for change across recruitment training and education for support workforce have been made 26 the evidence presented in this chapter has shown where gaps exist in knowledge about how to develop staff across health and social care services the issues highlighted show how it is timely for a review of workforce development for the support workforce to understand what works and to develop the skills and knowledge of staff review question and aims this review was designed to identify interventions at individual team and organisational levels that have the potential to enhance skills and care standards in the support workforce for older people in addition the review was designed to uncover how and why workforce development interventions may impact and on whom in order to guide future workforce development policy and practice our research question asked how can workforce development interventions improve skills and care standards of support workers within older peoples health and social care services the main aims of the study were to 1 identify support worker development interventions from different public services and to synthesise evidence of impact 2 identify the mechanisms through which these interventions deliver support workforce and organisational improvements that are likely to benefit older people 3 investigate the contextual characteristics that will mediate the potential impact of these mechanisms on clinical care standards for older people 4 develop an explanatory framework that synthesises review findings of relevance to services delivering care to older people 5 recommend improvements for the design and implementation of workforce development interventions for support workers chapter 2 methods introduction following recognised realist principles and published guidance 65 66 67 and drawing on the previous experience of the team in undertaking realist review 6869 we followed a number of stages in completing this project however unlike the stages of a traditional systematic review which tend to follow a linear path the process of a realist review is more iterative this is because the review is theory and stakeholder driven and it is the process of theory development and refinement that guides the search for evidence the review of evidence and ultimately the synthesis process this process goes back and forth and although we have presented the methods in stages below we have attempted to reflect an iterative process in the narrative in this chapter we provide a detailed description of each of the areas of evidence which informed programme theory development refining and testing in this report we have used the rameses publication standards 67 stakeholder engagement including patient and public involvement stakeholders are key drivers in realist work the realist synthesis focus is driven by negotiation between stakeholders and reviewers and therefore the extent of stakeholder involvement throughout the process is high 67 stakeholder contributions for realist synthesis can include clarification checking meaning and developing theory 7071 for this review stakeholder engagement was designed to help the research team elaborate on the review context refine the review questions contribute to programme theory development and interpret the evidence stakeholders were involved in a process of prioritising and refining the theory areas and making additions the research team adopted a systematic approach to stakeholder identification based on an impact and influence matrix 72 to ensure that the most appropriate people were contributing to the review lists of potential stakeholders were drawn up to show who they were and to consider their potential input for the review stakeholder categories included users of services providers of services service commissionersfunders and other relevant bodies stakeholder engagement also incorporated the interactions with the project advisory group members we identified 13 categories of peoplegroups who could bring different perspectives to the study to help to identify levels of involvement with the project the categories were then analysed further to consider the interests of the stakeholders and how hypothetically they could affectbe affected by the studys aims and objectives consideration was given to the stakeholders interest their particular influence potential impact level expected concerns and stakeholder management throughout the studys duration the results of the stakeholder analysis were mapped onto a matrix to give consideration to the levels of influence and impact expecting that levels of engagement for different stakeholders would change during the studys duration in addition we searched for people active in representing older people at community level to secure patient and public involvement in the project team and steering group three individuals were nominated and accepted the teams invitation to participate they became project team members and are coauthors of this report stakeholder engagement in the review was as follows l participating in workshops to explore the nature of and identify key issues in workforce development for the older persons support workforce l advising on priority issues within the review theory areas l commenting on iterations of the plausible hypotheses and contextmechanismoutcome configurations l advising on specific stakeholders to participate in interviews l advising on knowledge mobilisationincluding through a wenurses twitter chat in addition ppi representatives attended all monthly meetings of the project team and were consulted on specific issues in between representatives also attended initial exploratory workshops along with other stakeholders and this led the construction of some review artefacts including a plain english glossary of review terms changes to the review process no changes to the review process were made subsequent to the publication of the review protocol 73 rationale for using realist synthesis realist synthesis is theory driven in this way realist synthesis works under the principle that it is the unseen elements of a programme that lead to its success or failure contingent relationships are expressed as cmos to show how particular contexts or conditions trigger mechanisms to generate outcomes mechanisms are the pathway from resource to reasoning and response 74 and resources can be described as those that are material cognitive social or emotional 75 the reasoning and response may stem from the perspectives of the receivers the organisers or those involved in the delivery of programmesinterventions as pawson and tilley remind us social programmes are theories incarnate 76 programme theory describes the theory built into every programme 77 and is expressed in this way if we provide these people with these resources it may change their behaviour 75 different sources of evidence are used to construct programme theories but they emerge from a systematic process that includes stakeholder engagement an overview of relevant extant theory 77 and scrutiny of primary research 78 in this review theory development work was undertaken in phases 1 and 2 to articulate theories about what works in workforce development for the support workforce in health and social care and the conditions that might make them successful methods nihr journals library workforce development interventions for the support workforce for older people are complex social programmes involving people structures and organisations in this review workforce development interventions were defined as the support required to equip those providing care to older people with the right skills knowledge and behaviours to deliver safe and highquality services 22 as such the way in which they might work will be contingent on a variety of factors and therefore synthesising evidence to explain this required an approach that could accommodate both complexity and contingency we consequently undertook a theorydriven approach to evidence synthesis which was underpinned by the realist philosophy of science and causality 6773 programme theory development and refinement involved in a number of interconnected processes including l scoping the literature ¢ concept mining ¢ conceptualising workforce developmentstakeholder workshop which was guided by soft systems ¢ identification of theory areas l searching processes l selection and appraisal of documents l data extraction analysis and synthesis processes the process and outputs of each of these activities are described in more detail in the following text scoping the literature concept mining concept mining was undertaken to map evidence about the support workforce workforce development interventions older peoples services how interventions might operate and any reported enablers or barriers to the successful implementation of interventions concept mining in realist synthesis describes a process of searching through different bodies of evidence for information that could help build theories in this review concept mining involved searching through different bodies of evidence for information that could build theories about workforce development the starting point for the review was the commissioning brief which was subsequently reflected in the funded proposal 79 in a background search of some policy documents 416063 we found literature about the perceptions of support worker roles gaps identified in skills training how training and development should be structured for the support worker approaches to workforce development professionalism and the working environment key concepts identified from this background search included l how support workers who feel valued and empowered are more likely to promote dignified care l how management support in the workplace can enhance autonomy and decisionmaking l the challenges of overreliance on personal experience without specific guidance l continuing professionalisation of care work so that support worker roles can be promoted l how personal development can build knowledge and skills l dimensions of quality including dignity communication and understanding of the older person as an individual l use of multiple flexible learning and teaching strategies to promote confidence l increase of the attractiveness of care work through the provision of development opportunities to guide our development of the programme theories we conducted an initial exploration of theory which might help to show how workforce development should work and identify what factors can supposedly support or hinder its success for example learning from theories of professional learning which included the role played by informal learning 80 and role progression and the development of expertise in developing learning 81 we drew on the work of authors 64 to consider how the mental activity required for skill acquisition varies from novice to expert theories of adult and transformational learning were also relevant to be considered in the context of how interventions may be underpinned by holistic education taking into account cognitive affective and psychomotor domains 82 we also examined how workforce development is defined in other disciplines for example education 8384 and employment 85 we considered variation in workforce development implementation for the support workforce 26 issues of workforce changes and substitution 31 and how to link different development interventions and workforce functions 33 theories of behaviour change were also considered as they focus attention on how to develop individual skills and knowledge 86 from an implementation perspective we considered how knowledge use may be influenced by factors related to the work environment and facilitation 87 and from education how the choice of intervention should suit the context 88 we also mined the practice development literature to be cognisant of how workplace cultures can be improved 89 we also felt it important to take into account the role of organisational and other contextual influences that might influence workforce development methods nihr journals library intervention design delivery and evaluation including individual team and organisational foundations for learning organisations 9091 and other factors which enhance or act as barriers to learning 92 conceptualising workforce development at the beginning of the project we held a workshop in which stakeholders contributed to the development of the scope and issues that are relevant to the workforce development of support workers with older peoples health and social care services the workshop was facilitated by two members of the research team stakeholders were purposively sampled to ensure representation from relevant constituencies the structure of the workshop was guided by soft systems thinking a learning approach which offers an interpretive perspective of the complex and adaptive nature of human systems such as workforce development within the real world 9394 soft systems methodology complements the realist approach used in this review as it takes into account how complex systems within which programmes or interventions are situated may be underpinned by different perspectives 95 we found that applying the principles of soft systems methodology helped the team to operationalise the workshop in a structured way in addition soft systems methodology helped us to guide stakeholders thinking so that they could shed light on some of the complexities behind workforce development for support workers we chose this approach as we assumed workforce development to be transformative of both individuals and contexts with the potential for both complementary and conflicting structures processes impacts and perspectives we applied the principles of soft systems in two ways 1 the use of the catwoe mnemonic to structure data collection discussion and analysis 2 the generation of rich pictures describing how workforce development works the catwoe mnemonic provided a structured way of thinking about the complexity of workforce development programmes by focusing on the beneficiaries of workforce development the roles and functions of people within workforce development the changes that workforce development makes the beliefs about what is important in workforce development issues of leadership and physical and other constraints on the system 95 the first phase of the workshop included table discussions around the catwoe issues the output from these discussions was used to develop rich pictures to illustrate the complexity of a workforce development system by linking the catwoe elements for example the rich pictures provided the basis on which to develop a stakeholderdriven textual summary of how workforce development for the support workforce for older people should operate l the effectiveness of workforce development interventionsprogrammes for the older peoples support workforce can span outcomes for the workforce for the delivery of services for older people and their carers and for organisations interventionsprogrammes are most effective when positive impacts from workforce development can be identified in all of these areas for example changes in the knowledge and skills of the support workforce will often require changes in organisational systems or processes for benefits to be accrued by older people and vice versa when these impacts do not meet the expectations of older people or health organisations then positive individual changes from workforce development programmes interventions might be evident but might not be sustained l workforce development will be effective when it is aligned with organisational and other career development frameworks and opportunities when these frameworks are used to design and evaluate workforce development benefits for individual members of the workforce may have greater visibility and meaning l effective workforce development is designed implemented and evaluated with the older peoples support workforce and practice programmes or interventions that are neither grounded in the reality of daily work completed by the older peoples support workforce nor delivered within in the workplace are less likely to be effective l effectiveness can be mediated by the personal characteristics of members of the older peoples support workforce aspects of human and social geography characteristics of the organisations in which the support workforce is operating workforce and service policy and public experiences and expectations methods nihr journals library identification of theory areas this initial conceptualisation was used to generate a longlist of issues in four theory areas for focusing the review these were reviewed and prioritised by stakeholder workshop participants and then by the project advisory group members in a facetoface meeting they were broadly grouped into theory areas career development and strategy design and delivery and mediating factors and impacts searching processes as theory development work was under way the process of developing the search strategy continued led by the projects information scientist and involving the research team and feedback from the steering group the process involved searching for evidence relevant to the theory areas reflecting the realist approach the search strategy was broad and eclectic 96 and combined a primary search and purposive searches in order to capture the most relevant evidence to support or refute the ideas within the initial programme theories for the primary search a list of search terms was created from the theory development work search terms used for the support worker captured data to inform the mediating factors theory area in addition further searches found other data relevant to mediating factors test searches were set up in medline cumulative index to nursing and allied health literature and social services abstracts and titlesabstracts were inspected for search terms longlists of terms were drawn up for support workers workforce interventions and outcomes for support workers older peoplecarersfamilies and organisations the search term list for the support workforce was adjusted to include terms that emerged from scrutinising the literature for example care attendants healthcare aides personal support workers hybrid workers and care providers search term lists were rationalised and checked against mesh when available and checked alongside the developing set of programme theories search terms for support workers in education and policing were also retrieved for example para educator special education assistant aide instructional assistant paraprofessional police community support officer special constable and operational support grade the logic for deliberately looking beyond health was to refine the emerging findings from the health and social care literature and to ascertain whether or not there is any crosssector learning given that support roles exist in other public services primary search of databases the major health social and welfare databases were searched using keywords identified through the search development and database specific keywords adapted for each information source methods nihr journals library purposive searches in realist synthesis a cochranetype systematic search strategy is unlikely to yield all sources to inform the testing and refinement of the programme theories 97 in a review related to complex evidence only 30 of sources were obtained from the database and handsearches while 51 were identified by snowballing and 24 were obtained through personal knowledgecontacts 98 in the current review purposive searches of the evidence were conducted to provide specific focus on the programme theories the primary search for references was augmented by other searches for support worker role evaluations or intervention research which made specific reference to embedded implementation or impact purposive searches were also conducted in allied and complementary medicine database health management information consortium education policing and the practice development literature in addition a handsearch was conducted in the british journal of healthcare assistants other papers were added through snowballing from database alerts and from project group and stakeholders internetbased searches for grey literature were conducted for workforce development project reports national inspection and regulation quality reports and evaluative information about these initiatives selection and appraisal of documents evidence was excluded only if did not relate to the theory areas the test for inclusion was if the evidence provided was good and relevant enough to be included 96 drawing on the previous experiences of the research team 6669 data were extracted if they were good and relevant enough 96 the test of good and relevant enough is potentially vague and could lead to a lack of transparency about decisionmaking therefore through critical discussion within the core team we developed an additional subset of constructs which were added to the data extraction form in the form of a flow chart the flow chart provided a set of additional questions which affirmed the judgement made of the extracted data and reported its potential to contribute to the review good enough was deconstructed as the quality of evidence expressed through fidelity trustworthiness and value relevance related to the contribution of the evidence to the theories member checking with reviewing took place within the research team titlesifting was crosschecked across three team members levels of agreement across reviewers were scored for 6 of the total titles the titlesifting example was also checked with jrm cb lw and bh data extraction analysis and synthesis processes in realist synthesis theory development refinement and testing is an iterative process of review and refinement and is made visible through bespoke data extraction forms 6696 as such data extraction was undertaken in an iterative way across the review 99 initially a bespoke data extraction form was developed from the four theory areas to provide a template to extract evidence member checking with extraction took place within the core research team a sample of evidence was crosschecked across three team members data were organised into evidence tables representing the four theory areas in addition data were organised into evidence tables representing a continuum ranging from conceptual to instrumental to direct impact 100 as we were extracting data we also began the process of synthesis the realist synthesis is theorydriven and uses abduction to understand cmo configurations 101 synthesis is a process of triangulation 102 that melds different sources of evidence in a process of theory development testing and refining through the previous experiences of the research team 6669 and building on the suggestions of pawson 96 and the principles of realist enquiry we undertook an abductive and retroductive analysis of evidence across the tables to look for emerging demiregularities reflecting the interpretive nature of the review the quality and relevance of the evidence was assessed during the synthesis process 103 through weighing up the contribution of each piece of information to the development of the explanatory account and to the review question and aims 74104 this contrasts with traditional cochranetype reviews which support the use of more quantitative statements of how much evidence to underpin the findings 1 if workforce development is closely related to practice then the intervention is more relevant and more likely to be applied 2 taking staff away from practice for workforce development results in them feeling as if there has been an investment made in them and gives them more headspace and they are more likely to feel valued by employerorganisation 3 depending on the natureissuepurpose of the workforce development intervention a multiprofessional approach to learningdelivery is more likely to be effective and engender cohesion 4 when design and delivery of workforce development is seen to be credible support workers will engage moreit will have more relevance 5 when workforce development integrates personal perspective and professional perspective so that the support worker knows what is expected of them it may have more relevance 6 whenif workforce development fits with the organisational strategyphilosophy then the support worker will feel more valued 7 if the focus of workforce development is on where people are coming fromstarting from and design and deliver interventions around this then the interventions are going to be more effective 8 if workforce development is operating at more than one level then the impact is likely to be greater 9 if workforce development is appropriately targeted at individual team organisation system then it is more likely to be effective 10 when workforce development reinforces behaviour and learning it is more likely to be effective 11 when workforce development is aligned with incentives it is more likely to be effective 12 if there is a clearly articulated predefined theorypostulated mechanism of action about workforce development then it is more likely to be effective 13 when implementation features are embedded in the design and delivery of workforce development it is more likely to be effective reflecting the iterative refinement of the theory development process these plausible hypotheses led to a revision in the data extraction form we did a further dive into the evidence with this revised data extraction form following data extraction of the whole pool of evidence tables were developed that summarised the evidence we extracted relevant to each plausible hypothesis these evidence tables were then used as the basis for further deliberations about the emerging contingencies we could see within and across the extracted data the extraction and synthesis process was managed on a daytoday basis by the local research team with regular input from the wider project team including our patient and public representatives this deliberative and iterative process enabled iteration from plausible hypotheses to the uncovering of cmo configurations the result was eight configurations which are summarised in table 2 an evidencebased narrative was developed under each cmo configuration by drawing on evidence in and across the data tables programme theory testing to enhance the trustworthiness of the resulting cmo configurations and to facilitate the development of a final review narrative we conducted 10 semistructured audiorecorded interviews with stakeholders we used a mixture of purposive and snowballing sampling to obtain the perspectives of people who would reflect those who would have a stake in the findings the interviews were structured for the purposes of testing out the cmo configurations with data confirming or disputing each mapped directly onto the cmos the interviews facilitated the development of the final cmo narrative our sample comprised managers directors for trainingdevelopment and support workers an interview schedule was developed based on the cmo configurations to elicit stakeholders views on whether or not they resonated with their experience and whether or not and how they might operate in practice all the interviews were conducted by telephone and lasted between 45 and 60 minutes all interviews were audiorecorded and concurrent detailed notes were made the audiorecordings were fully transcribed as the interviews were structured for the purposes of testing out the cmo configurations data confirming or disputing each were mapped directly onto the cmos in fact the interviews provided mainly confirmatory evidence of the cmos and provided some additional contextual evidence to each evidence from the interviews is combined in the narrative for each of the cmo configurations reported in the next chapter ethics the study fell outside the scope of nhs and social care requirements for ethics review however we sought ethics approval from bangor universitys research ethics committee to conduct the interviews chapter 3 findings introduction as chapter 2 outlined the theory development refinement and testing process led to the distillation of eight cmo configurations these are explanations that cumulatively constitute a programme theory about what works in workforce development for the older persons support workforce these cmo configurations emerged from the evidence and were verified with stakeholders they are not mutually exclusive and we hypothesise that in order for workforce development interventions to have maximum impact paying attention to elements of each will be important in realist review the analytical task is to draw across the evidence base to provide explanations expressed in the form of cmos in other words it is rare that one cmo is reflected in its entirety in a single piece of evidence therefore we describe each cmo configuration in terms of the underpinning evidence drawing on the included studies interviews and stakeholder perspectives which have been embedded in the conduct of the review illustrative excerpts from the literature and quotations from interviews are embedded in these explanations to highlight meaning and salient points we also include some practical examples of the ways in which the components of each cmo were visible in the interventions included in the review the review process including findings from stakeholder interviews resulted in eight cmo configurations context and mechanism a strong relationship was evident between the proximity of the workforce development intervention and reallife work of the support worker and specifically whether their work was immersed or disconnected from the intervention proximity was a feature of development initiatives that were closely aligned to the work of the support worker delivered in practice or closely related to practice proximity prompted feelings of resonance when the intervention focused on what the support worker might experience in their work and what was familiar and relevant to them there were two different forms of proximity in the evidence l cognitive proximity 106 107 108 109 110 112113115 117 118 119 121 122 123 124 125 128 which was evident in intervention specifics or content and judged by the extent to which the applicability of the intervention to the support workers own work practice could be observed andor l physical proximity 105107111 114 115 116 120126127 reflected in intervention delivery was physically located in the support workers workplace cognitive proximity when the design of interventions was intentionally focused on the role and work of the support worker this was more likely to prompt resonance this was exemplified by learning tools and techniques that drew on reallife work supervision of practice working together and focusing on the individual including the use of films 108109 to teach personcentred caregiving skills to support workers from an older persons service one intervention included the viewing of putting person before task a 7minute film showing support workers modelling personcentred care as the basis for participation in further roleplaying activities visual depictions of the reality of older persons services and experiences were also used to make the intervention more engaging 121 visual tools such as photographs of various situations and storytelling became the bases for discussion the emphasis was on doing experiencing discussing and team problemsolvingrather than didactic teaching p 3 cognitive proximity also featured in interventions that paid attention to the personal backgrounds of older people case studies of care home residents were used in one intervention to enable support workers to link the needs of care home residents with their knowledge of the person 121 resonance with the work of the support worker was also evident in interventions which focused on individual older people within workers services in this case certified nursing assistants through for example the creation of care home residents biographies 108 an innovative way of making personal information about residents available to cnas creating videotapes of cnaresident caregiving interactions and using them in conjunction with behavioral observation instruments is an innovative way to promote cnas selfawareness of the person centeredness of their caregiving behaviors p 697 interventions similarly driven by biography invited support workers to share their feelings about caring with people with dementia 128 and helped staff to get to know the person they were caring for 118 collecting biographical material about peoples lives helped them to gain a more dynamic and complete picture of those for whom they were caring and that knowledge of peoples life stories enabled them to find out more about residents needs and behavior p 701 role play with a facilitator playing the role of an older person in a residential care setting was used to teach communication skills so that the support worker could learn how to individualise their approach 117 support workers learned the significance of information in the individual biographies of the older person in shaping communication in addition homework sessions were included to promote selfreflection about actual practice in which participants were asked to design a shortand a longterm care plan to address the specific needs of an individual resident 117 and overcome a carerelated problem that they identified within their own clinical settings 110 this was reviewed at sessions with their peers and mentors the use of care planning strategies that drew on realworld challenges such as how to deal with challenging families also ensured that the intervention had workrelated meaning and significance for the support worker 110 in training for care staff to recognise depression in residential care settings 127 a bespoke care planning intervention was implemented over an 8week period with support workers working together with residents to plan their care and supported through weekly onetoone supervision sessions over the 8 weeks interview data reinforced the utility of developing sharing and reviewing care plans to bring learning to life for example i think one of the things that we did that was really beneficial was writing our own care plans together and looking at how intricate we were as people and how bizarre some of the things were that were important to us as people and i think for me it was quite a learning curve as a manager telephone interview participant 1 in a series of seminars provided by a multidisciplinary team a similar attempt was made to ensure that the intervention was congruent with the support workers own experiences of work the main aim of goal planning was to encourage care staff to formulate a specific and detailed care plan with a view to positively changing problematic areas of a residents behavior p 234 125 other aspects of workforce development interventions that enabled proximity to the work of the support worker included experiential learning approaches 121 which enabled the support worker to experience the difficulties that frail residents faced and to identify the care practices that could be used to ameliorate those difficulties 121 in a different report proximity to the work of the support worker was supported by a clinical component to the education course which consisted of 24 hours of handson patient care in a longterm facility under the direction of the course instructor 106 fortnightly group supervision was complemented by individual training sessions for support workers in care home settings 107 whereby trainers observed support workers at their work and provided feedback when there were opportunities for support workers to share experiences through group debriefing 115 groups were established to use the experience of caring for a resident who has died as a basis for learning about endoflife care 115 in this case the groups were led by a nurse specialist in palliative care and open dialogue approaches were used to encourage engagement in addition it was reported that debriefing promoted reflection in action and made the intervention realistic for participants 119 cognitive proximity also featured in other examples including case conference style approaches in which registered professionals chose the topics and led the case presentation and discussion 124 this helped to capture support workers imagination and challenge their own thinking the benefits of more interactive approaches that included the discussion of cases were reinforced in interviews for example were also using supervision and appraisal very much as a training tool so i think weve missed a trick there with those its been a little bit are you ok yes you are thats fine off you go actually using that to really encourage discussion looking at particular case studies so its more like a clinical supervision telephone interview participant 1 in addition to the use of vignettes practice tools and biography to bring work with older people to life for participants desirable aspects of the support workers work were made evident in other parts of workforce development interventions this included an application process which used a questionnaire a written essay and an interview for participants to access the intervention in this example applicants were expected to model professional conduct 106 and contracting was included at the start of the intervention to promote the modelling of professional behaviours 106 and to specify prerequisites related to the support worker role 129130 there was also evidence to illustrate the advantages of drawing on the experience of older people themselves in the delivery of workforce development in making learning real for example in a paper that reported a feasibility study of an education programme we found that the delivery included people with aphasia as educators 131 which was designed to improve nursing assistant students knowledge of aphasia and supported examining the experiences of participants with aphasia physical proximity proximity to the work of the support worker also featured in a physicalgeographical sense when interventions were deliberately based in the workplace 106107114127 these included interventions that facilitated competencybased assessments 126 focused on behaviour strategies to support the work of the support worker 112 for example learning how to give instruction in small steps or improving the level of stimulation in a service setting alternatively some workforce development interventions were designed to enable support workers to make and understand the close link between the intervention and the context of work when an intervention was situated in the workplace and designed to fit with the working pattern of the staff being held during shift changes this maintained a theoretical and practical link with the daily routine of the institution each topic to be taken up in the training program would be closely linked to life in the institution with the aim of fulfilling the special needs of the residents of the particular institution 112 there was consistency with literature about teaching assistants in schools in which evidence also supported the importance of physical proximity where workforce development for teaching assistants was held in the workplace 123 there were increases in the congruence of the intervention with teaching assistants experiences which encouraged colearning with other colleagues thereby encouraging teachers and support workers to learn from each other in partnership 123 taking support workers out of the workplace for workforce development we found a different perspective or contradictory evidence around physical proximity specifically about the positive impacts of removing support workers from their work area and that learning could be better enabled through the provision of separate space with less disruption 105123 131 132 133 for example facilitating workforce development on weekend days away from support workers jobs was linked with positive impacts about participants knowledge and attitudes 105 an intervention to improve participants awareness and knowledge about aphasia delivered in a college setting demonstrated improved learning about aphasia in addition in this study participants demonstrated greater incorporation of new learning into their work interview data affirmed the feasibility and positive impacts findings nihr journals library of taking staff out of their work context to participate in workforce development but noted caution in ensuring no negative consequences for the organisation variety and change of scenery does make a difference to peoples learning habits and what they learn and how they learn without a doubt and i agree with that completely we also have to do what works well for our organisation within our care delivery demands as well so its finding that balance telephone interview participant 3 in two other interviews reference was also made to the benefits of providing opportunities for support workers to gain understanding of other organisations settings in which it was interesting to see how different some of the homes operate and useful for crossfertilisation further from the education literature we noted reports of interventions which encouraged taking teaching assistants out of the classroom to visit other schools and view different practices 123 regardless of the pros and cons of the physical proximity of workforce development the interviews highlighted the need to think systematically about the delivery location by focusing on its combination of practical or theoretical content i think a lot of it depends on the type of training if youre going to have an academic session thats looking at the impact of immobility on tissue for instance you want to have a session on pressure area care that can be beneficial in the care home setting so in xxxx there would be some quite logical sense in doing that because you can then say ok were going to go along and see so and so after weve done this and well look at our tissue areas and their pressure areas and well look at the colour of them well look at the state of her skin well look at the state of her hydration and nutrition and you can then make the training wheel that kind of training i consider to be essentially practical if youre looking at something thats perhaps more theoretical going to talk about say lets say its going to be the impact of certain drugs on someone whos got vascular dementia the effect theyre going to have that works quite well in more of a classroom setting because you can focus you wont have the distractions of being in your workplace you wont have call bells going off you and your students will be able to concentrate on the academic side the technical and the academic rather than the practical telephone interview participant 9 this interviewee went on to describe the positive personal impacts for support workers that taking them out of the workplace might bring when taking someone away from their workplace and sending them to somewhere as a novelty value creates a break and that in itself is quite a positive thing taking participants out of the context of practice may also have implications for continuity of learning in that learning that has happened away from the setting may have to be reinforced when back in practice to make it real outcomes proximity in workforce development in either a cognitive or a physical sense prompted resonance with the individuals participating in it andor was more likely to lead to cognitive andor practice changes cognitive impacts for support workers included empowerment 114127 and improvements in selfesteem 114 together with increased knowledge and understanding of the behaviours of older people in their care 108 when interventions were proximal through the use of personcentred training role play and homework this led to changes in support workers mental models of their role and work 117124 for example coaching in the workplace led to an ahha moment for one care assistant and a positive difference in a care home residents behaviour as a result of the changes in behaviour of the support worker 117 practice changes included better cohesion and paying more attention to older people in efforts to meld theory and practice 111 and improved relationships with family members 113 the use of reallife case studies of older people in residential care settings as well as visual tools and storytelling also prompted resonance with the support workers practice improvements in the appropriateness and adequacy of care including for those older people with the greatest needs were affected after intervention 121 in situating interventions in the workplace practice changes as a result of making learning more real for the support worker included more attention being paid to older people 111 and relationships with family members improving 113 as well as more general aspects of service quality for example following completion of the educational programme there was significant increase in the proportion of care that was judged appropriate and adequate provided by healthcare assistants to residents than before p 8 121 summary in this cmo configuration we found that a relationship between the cognitive or physical proximity of the support worker and the workforce development prompted resonance with participating individuals which was important in terms of potentially influencing positive cognitive andor practice changes the relationship between proximity and resonance was made visible through the use of tools and techniques to draw on real life supervision of practice working together and evidence to prompt understanding and appreciation of older people themselves contextmechanismoutcome 2 where the support worker is coming from 106107109113121122129130 134 135 136 137 138 139 140 we were able to trace an evidence thread between tailoring to these factors and engagement with the intervention as the support worker is able to appreciate what is expected of them in the context of where they are at this finding was also reflected in interview data for example a lot of what were trying to do is get people to see that the skills and talents that they have outside of the service things that can be brought to work maybe other residents are interested in these things maybe they can support all different parts of life of the home and not necessarily just doing their set job and in that way you can sort of contributing to the sense of it being a whole home approach having a thriving community and having a lots of different kinds of varying activities going on in the service telephone interview participant 6 starting points included experience of work within older peoples services as exemplified in this excerpt from a report of a gerontological training intervention 132 in which sessions were experiential as well as didactic drawing upon trainees experiences and challenges this set the tone for interactive skills which role modeled communication skills for interaction with clients and families in a short programme aimed at sensitising nursing assistants in a longterm care setting to ageing and the experiences of older people 129 the intervention focused on the self and reflection including linking this to individuals existing values during the introduction an exercise entitled as we grow was used to elicit an atmosphere conducive to selfexamination this exercise required participants to write down seven of the most important things in their lives 129 extending beyond selfawareness workforce interventions to teach personcentred caregiving skills to support workers also indicated benefits in the workers emotional engagement with older people 109 personcentred caregiving was associated with interpersonal complexity or support workers abilities to view older people in ways that are not stereotypical the intervention included discussion about the importance of identifying how individuals perceive others and found that cognitive complexity is associated with motivational factors such as the goal of forming personal relationships with residents being able to select talented caregivers would be of direct benefit to facilities and could reduce the need for training 109 other attributes accounted for in workforce development included individuals earlier life or workrelated experiences of learning an evaluation of a simulationbased intervention demonstrated that both previous experiences of formal education and a reliance on experiential learning about the support worker role were instrumental in influencing support workers learning experience 122 this was highlighted by a ward manager reflecting on the programme that in the past most support workers have learned with time and through experience working alongside trained nurses knowing the expectations of the trained staff thats probably time served experience 122 interviews with service managers confirmed the importance of experience and age in tailoring workforce development to the individual so we actually look at what the individual has achieved already and then we match that up with things that they could also do that theyve not done for whatever reason we do take a lot of interest in each individual telephone interview participant 5 in addition to acknowledging the role of emotional attributes and prior experiences of learning some evidence targeted the mental models that support workers held about the nature of care settings services and older people 124 in a case study set in a residential care in the usa two mental models were identified as guiding certified nurse assistants in their work and their interactions with older people understanding individuals mental models because they might not be a good basis for appropriate care actions 124 can be a starting point for reframing them although not linked specifically to workforce development an acknowledgement of the importance of personal resources was reflected in the nonhealth evidence in a report of a research study about the police community support officer role in england we found a similar pattern between the age and life experiences of the support officers and their effectiveness within the role which appeared to be easier for the older pcsosthose who had a wider range of life experiences from which to draw this is not to say that the younger pcsos were not effective in the rolethey were and they often seemed to be more at ease behind a computer screen than their older colleagues 140 abilities our second interview participant raised the importance of paying attention to individual ability theres something about acknowledging the stage that learner is at in their career or their learning pathway there was also evidence of drawing on individuals own abilities in the design and evaluation of workforce development individuals communication skills were the focus of a training package for care home staff to enhance their interactions with older people 139 and in a critical analysis of a communication skills training programme for nurse aides set in the usa 138 the effectiveness of communication skills was assessed prior to the intervention during 5minute care interactions with residents using a communication skills checklist this was also important in establishing that an increase in the use of effective skills and instructions and a decrease in ineffective instructions by support workers during care interactions and maintenance of these changes for 3 months 138 had occurred evaluation of a computerised educational programme for nursing assistants in endof life care 134 included exploration of the following characteristics 1 ease of use 2 clarity of presentation 3 appropriateness of reading level and content and 4 relevance to nursing assistant practice 134 in this example the use of learning approaches that paid attention to the existing abilities of the nursing assistants in literacy and language were explanatory 134 needs of users with low literacy skills and diverse learning styles are addressed by incorporating slides art video clips and audio clips other features to increase ease of use for those with diverse learning needs include a glossary indices a simple search engine and selfgrading quizzes p 504 134 similarly in a workbased learning programme for support workers in assisted living based in oregon usa 135 paying attention to literacy and language needs enabled the intervention planners to factor in additional time to maximise the effectiveness of the programme for staff findings nihr journals library role expectations we also found that the design of some workforce development interventions supported the sharing of individual expectations about the support worker role participation in a simulationbased educational programme required support workers to express their own expectations about their role development 122 interventions promoted the career development of support workers including the use of job analysis to understand existing and required competencies for the role 135 other interventions focused on career progression incorporating principles such as professionalism selfefficacy selfworth and maximising intrinsic motivation 132 so that the design was grounded in an intention to encourage a more careerfocused orientation 132 outcomes situating and tailoring workforce development in the context of the personal and role starting points and expectations of support workers was more likely to prompt commitment leading to increased levels of engagement with the intervention and potentially with the older peoples service this was achieved through improvements in team working clinical knowledge and skills and relationships with residents 141 for employers impacts were in terms of better management of challenges 105 including support workers being more creative in handling challenges that come up for them 105 through a cycle of reinforcement these impacts appeared to extend to a better appreciation of staff by family members 113 the results may also suggest that when staff members feel more appreciated by family members they feel more able to have cooperative conversations and feel more empathy the above can lead to staff forming better and more cooperative relationships with family members which may improve their working life p 319 113 in an intervention which featured selfassessment and lifestyle change for the support worker caring for themselves could help support workers to better care for older people expressed through increased feelings of worth and belonging 107 in another intervention designed to promote a careerfocused view and enhance professionalism selfefficacy and selfworth a deeper commitment to care work was found 132 personal outcomes related to more confidence pride and feeling rewarded 141 and valued 142 these outcomes also emerged in interviews but were linked to service improvement for which one manager felt that it is as much about the worker as it is about the resident and it works because they feel valued its reciprocation i mean look at it is if you treat somebody as a human being and you listen to them and you really really support them to do their best they start to totally reciprocate with residents summary if workforce development pays attention to the individual support workers personal and role starting points for example personal resources abilities and personal feelings and expectations then this leads to increased levels of engagement with the intervention workforce development interventions can examine support workers personal resources build on recognise and value different abilities and harness existing resources in development activity in addition to engagement with the intervention this may enhance support workers engagement in their service it also leads to personal outcomes such as confidence empathy selfesteem and satisfaction which may be linked to other outcomes for older people families and services contextmechanismoutcome 3 tapping into support workers motivations if workforce development opportunities include elements of incentivisation then it is likely that participants will feel recognised and rewarded the relationship between incentivisation and having a stake in workforce development can lead to greater emotional and practical participation and engagement with the intervention context and mechanism incentivisation was noted to be a strong thread within the analysis interpreted as efforts within the design and delivery of interventions to motivate individuals and to ensure attendance at and completion of the intervention these efforts included certification to recognise engagement in interventions 105120127140 and the use of prizes 112138143 and financial incentives 106127133141144 in its simplest form we found evidence that the use of certificates of attendance triggered a sense of reward 105120127 in a communication skills programme 120 and an intervention to recognise depression in care home settings 127 certificates were also used to recognise completion of the intervention successful completion of a short curriculum for direct care workers set in the usa resulted in completion certificates for the participants being provided but these were designed to be relevant for employers in the local area 105 from the policing literature we found supporting evidence that certification should be offered to recognise support officers development of skills and abilities 140 when a pcso contemplates leaving the organisation to move on to other work many are left with the impression that they have nothing to show for it when it comes to their experiences as a pcso many of the abilities they have gained are of course transferable to other organisations p 23 140 theoretically certificates of engagement and achievement in workforce development should increase prospects for those support workers who wish to progress within or move between organisations however we found little evidence that examined the consequences of this type of incentive mechanism other than in the above aspirational excerpt from the policing literature other than rewarding attendance and participation by certification other incentives were used to motivate support workers to complete and engage in ongoing workforce development programmes practical approaches included public posting of progression reports for support workers and using prizes as rewards for specific performance targets 138143 in an intervention in which support workers were taught to use communication skills with residents with cognitive impairments a comprehensive staff motivational system was used to encourage individuals to sustain their new performance and skills 143 some incentives were certification prizes and perks financialmonetary investment findings nihr journals library designed to include an element of choice so that the prize was more relevant for the individual choosing it however in the example below the personalisation of incentives within a lotterystyle draw was constructed in addition to a public recognition of performance for each shift the individual winning the lottery was provided with his or her choice of incentives from a list of choices determined by each nursing home across nursing homes the most frequently chosen incentives were the opportunity to leave work earlier than scheduled extra pay and goodie bags p 453 143 lotterystyle approaches to incentivisation featured in other evidence including a development to incorporate informed teams as a vehicle for staff development in care homes 112 weekly draws and prizes were used to encourage staff participation in daily meetings and skill sessions as well as other incentives used to encourage engagement by the participants lottery reward systems were also associated with intervention tasks in the case of the completion of selfmonitoring documentation 138 the impact on staff engagement was evident by the fact that when the reward system was withdrawn compliance with the selfmonitoring task decreased significantly in this context lotterybased reward systems may be successful only in raising awareness of expectations of workforce development rather than in affecting more fundamental and sustained cognitive and behavioural changes from interview data we also found that there was an impact in terms of staff feeling recognised and rewarded if incentives were offered it may seem insignificant to others unless youve ever been to one we do a presentation every year for the learners and the staff who achieved we have something called the smile award and its a little initiative that i find that makes the difference and were not giving them £50 bunch of flowers were giving them a nice pen certificate and a badge and they love it telephone interview participant 7 a range of different organisations used monetary investment to engage the support workforce with development the evidence to support the use of financial incentives was limited to some north american and european settings 106133141 and so may reflect particular professional and service contexts a financial contribution from the support worker such as a small course fee to attend a clinical module 106 could also lead to a sense of personal stake in the workforce developmentintervention financial incentives or remuneration from workforce development budgets were generally noted to be directed towards support workers turning up 106127144 financial incentives or remuneration from workforce development budgets were also noted to be directed towards support workers completing interventions the win a step up a programme of continuing education by onsite trainers for nursing assistants in care homes in north carolina was designed to decrease turnover and improve quality of care 141 the programme reported using financial incentives in the form of staff bonuses to ensure successful completion of the intervention an intervention that included peer mentorship for care assistants in a care home setting used the financial incentive of a 1020 increase in peer mentors salary or overtime or a reduction in workload in recognition of the additional work that the mentors took on 133 we also found reference to financial incentives being used to reward enhanced skills in stakeholder interviews we reward once staff attain a certain level of skills and experiences we reward that through pay outcomes monetary incentives were reported as generating positive impacts for the individual support worker for example managers reported support workers enhanced confidence and pride and feeling more rewarded 141 and selfesteem 144 outcomes from lotterystyle incentives were related to personal engagement with the intervention their work and the organisation in the development of a culture in which the work environment supports skill use with constructive feedback and recognition 112 there were also reports of positive impacts on the quality of support workers interactions with patients relatives from interventions which included evidence of incentivisation 144 when communication skills training used a motivational system which included prizes and perks the outcomes included increases in positive staff behaviours that were also sustained over time 143 summary we uncovered a number of ways in which engagement in workforce development was incentivised for support workers including the use of certificates prizes and perks or financialmonetary investment incentivisation may make it more likely that participants will feel that they have a stake in the intervention and feel more valued and motivated to participate which can lead to better engagement with the intervention lotterybased incentives on their own may not trigger sustained changes in desired workforce development outcomes and the use of financial incentives may be effective in only some service and professional contexts there may also be a case for tailoring incentives to make them relevant to the support worker contextmechanismoutcome 4 joining things up around workforce development if interventions are developed in the context of an organisations goals including their human resource and quality improvement strategies then this prompts alignment between the aims of the intervention and the goals of the organisation such that they mutually reinforce each other this leads to more sustained and lasting impact of the intervention reducing turnover and supporting the organisations retention strategy box 4 how joining things up is visible in the interventions included in the review care management staff development organisational strategy findings nihr journals library context and mechanism when the organisations strategic direction was made explicit in the reporting of how workforce development interventions were developed this generally showed alignment with the interventions aims there was evidence of joining up the organisations human resource strategy with support workers development needs 142 this included the development of leadership roles for senior support workers and preceptorship for new staff 110 coaching roles to ensure that support workers can benefit from coaching 117124 supervision 109 appraisal systems 140145146 and mentoring 127147148 other ways in which organisations prioritised development for the support workforce included reference to policies such as a mandatory attendance policy 112 allocating time for workforce development 112 and general efforts to develop support worker roles through bespoke workforce development strategies 117126 examples were organisational directiongoals to describe care management priorities that were important to the organisation for example quality of care 108 however we noted how the success of workforce development interventions was often contingent on how the organisation prioritised quality improvement 112 for example in a report describing the development and pilot testing of a 6week intervention for certified nursing assistants 108 the authors explained how the intervention aimed to identify and operationalise personcentred caregiving behaviours 108 in this way the intervention was set in the context of organisational efforts to improve the quality of longterm care more broadly through focusing on relationships and promoting culture change within care settings some interventions including an advanced education programme for nursing assistants in care home settings 110 and the development of a curriculum for paraprofessionals 142 were based on the needs of the service providers we also found studies that assessed the feasibility of interventions for support workers to recognise depression among residents in care homes for older people here support for staff to receive the intervention echoed the organisations direction following concern from managers 127 in another example 110 the aims of the intervention were aligned with the interests of external stakeholders in improving services aligning support worker development with the strategic aims of the organisation was also evident in the context of paying attention to the integration of health and social care for example a report of an inreach team project described the aims to develop a group of carers and support them in their role in integrated care for the older person 149 the benefit of developing the intervention to meld with the organisations strategic direction in this case supported previous research findings about the benefits of upskilling support workers in integrated care we also found in a paper describing the implementation of a support worker role in general practice evidence to support linking support workforce development to the organisations ethos about interprofessional working 147 outcomes alignment between the organisational goals and workforce development interventions had the potential for greater sustainability because the type of impacts realised could lead to longerlasting effects for example enhancing support workers commitment to their work 108 promoting better understanding of their work 145149 helping to develop positive attitudes 142 promoting more tolerance and more interest in residents behaviours 127 enhancing selfreflection 117 and leading to improvements in knowledge alignment of organisational human resource strategies and intervention design appeared to lead to better outcomes in terms of staff turnover and retention in this extract the choice of competencybased programmes which enhanced the competence and confidence of the support worker was perceived to be effective in increasing job satisfaction retention and career progression develop workbased learning programs that move lowwage frontline workers up health career ladders by improving skills and knowledge the initiative focused on developing competencybased training programs that would increase job satisfaction staff retention and career advancement and improve quality of care p 283 135 summary aligning workforce development with the organisations strategy has the potential to be reinforcing in that the context and content of development are relevant to the goals of the organisation this reinforcement has the potential to lead to longerlasting types of impacts for the individual and the organisation thus enhancing the sustainability of the investment made in the support workers development however there was little evidence in this context of a joinedup approach to a workforce development which linked learning with opportunities for career development personal growth and monetary and other rewards for skill and role development contextmechanismoutcome 5 codesign if the right mix of people are engaged in the design of workforce development programmesinterventions reflecting the complexity of workforce needs and desired development then this prompts codesign and a collective view about what needs to be done which can lead to workforce development that is more credible meaningful and relevant for the support worker with greater potential for positive outcomes for practice box 5 how getting the right people round the table is visible in the interventions included in the review in partnership multiagency working academic community with individuals specialists support workers national experts credible people findings nihr journals library context and mechanism we found that a key factor in intervention design was the makeup of the people involved in it the significance of getting the right mix of people involved in the design of interventiondevelopment programmes was made visible through reports of l design involving partnership and involvement of charitable trust funding 141 and partnerships with specialists 115142 multiagency collaboration in the design of programmesinterventions collaboration with academic staff 150 and communities l use of expertise 128151 in design l involvement of relevant staff in design 111113153 including the support workforce partnership between organisations when there was partnership working between different agencies in the design of workforce development programmesinterventions a codesign approach was reflected in the reporting a workforce development programme for nursing assistants in care homes set in the usa was described as an established partnership with established goals 141 the program is a partnership between the north carolina department of health and human services and the university of north carolina institute on aging p 72 141 similarly in a report of a skills development programme for direct service workers 132 the authors describe the extent of the multiagency collaboration involved and how taking a codesign approach informed the development of the intervention because it brought together the strengths and interests of multiple parties in academia provider agencies and professional associations garnered statewide support for the effort and ensured that concerns were addressed 132 this was discussed in the context of the development of a statefunded training curriculum for care staff 132 we found examples to show how partnerships were formed with academic and community partners in a collective approach for example a 6week collegebased course which constituted part of the preparation for support workers in the care home sector to achieve the nvq award was developed designed and delivered within a higher education institution in london 150 in a report of a pilot study that described the development and evaluation of a 2hour programme for trainee nursing assistants to promote personcentred caregiving skills with older people collaboration with community partners was instrumental in developing an operational definition of person centred caregiving 109 for trainee nursing assistants partnerships with the right individuals paying attention to the intention of the intervention related to who was involved in the design process we found that the intent behind collaborative intervention design was often twofold for example planning an intervention for support workers to develop their skills to deliver the right care was also aimed at supporting their personal development 151 similarly recognition respect and responsibility enhanced care assistant training was developed as a curriculum for nursinghome care aides to improve problemsolving and communication in addition to developing stress management skills in order to increase professionalism and selfefficacy 132 underlying the curriculum development was an emphasis on four selfefficacyenhancing methods mastery experience modeling social persuasion and altering emotional states the ultimate goal was to empower the direct care worker not just in terms of skills enhancement but to increase their overall perception of selfworth p 116 132 in a communityacademic project to deliver a gerontological intervention training for paraprofessional service providers 142 the design of the curriculum involved the trainees themselves selecting the topics and social workers with training in older peoples care were involved in the development and delivery of the intervention a policy of drawing on peoples experience and expertise was reflected in the report of developing curricula including trainers holding a master of social work degree related to gerontology and experience of working in a gerontological practice setting 142 this approach enhanced a collective view about what needed to be done similarly in an action research study that explored and developed quality endoflife care in two nursing homes using reflective debriefing groups to encourage open dialogue using the oral tradition of healthcare assistants 115 groups were led by a researcher who was a nurse specialist in palliative care 115 we also found evidence of curriculum content in which design was supported by national experts in the topic 136 or topic experts in gerontology 128 in one example a factor of significance for the programmes success alluded to by the authors was the credibility of the contributors to the curriculum design because they were national experts in palliative care and staff education 128 other evidence pointed to the significance of involving the most appropriate staff in the design of interventions including the support workforce themselves for example certified nursing assistants were included on a multidisciplinary expert panel to develop an educational programme for one faculty 151 elsewhere the evidence supported the principle of consulting with staff 113 in a report of an educational programme for nursing assistants working in longterm care nursing assistants the programme was designed by an expert panel including a physician a nurse practitioner a nursing assistant a palliative care nurse a hospice director and an administrator the authors suggested that the addition of the support workers enhanced the quality of the programme because participants suggested improvements to the content and format of the workshops especially the provision of more concrete and practical strategies for working with families 113 support worker engagement was also evident in the codesign of a framework for career progression for healthcare support workers incorporating three phases of continuing professional development 151 the programme was organised and coordinated by a dedicated support worker training team comprising four registered nurses plus senior support workers in the role of peripatetic nvq care assessors complementing the attention on involving support workers interviewees also highlighted the significance of involving family members in the design of workforce development for example very often they will have sometimes even more of an influence we find because very often older people themselves will not like to cause trouble will just want somebody whos kind to them whereas actually the relatives will often come in with a slightly dispassionate view and have different expectations and standards and so their input i think is really important in terms of design i would say again where ive worked in the past these things are often designed by a learning and development team of experts but actually involving staff managers and residents and relatives gives it a far richer input telephone interview participant 2 findings nihr journals library outcomes having the right mix of people engaged in the design of workforce development programmes interventions prompted codesign and a collective view about aims and objectives for example a programme funded by a charitable trust enabled the team to work together to assess the support workforce and develop a workforce intervention to improve their job satisfaction and retention 141 when intervention design and development engaged with the right people such as one example that drew on a dedicated support worker development team including registered nurses and support workers in the role of assessor 151 this implied a more collective approach and streamlined pathways including linking theory and practice when the evidence led to our conclusions that getting the right mix of people involved in the design of interventions can prompt codesign and a collective view workforce development was more likely to be credible meaningful and relevant for the support worker and promoted the potential for positive practice change as reflected in reports of individual and practice changes individual change a collaborative approach to the design of one programme found that following the programme the support workers became more orientated towards deep and strategic approaches to learning 150 a group of papers in which the authors reported involving experts in the design of programmesinterventions 134144150152 noted positive outcomes relating to individual knowledge ways of learning and enhanced selfesteem 144 one report of a curriculum whereby topics were prioritised by the paraprofessionals and trainers held a master of social work degree related to gerontology and worked in a gerontological practice setting 142 concluded that it was more relevant to the handson staff and the connection to the university made them feel special 142 practice change there was also evidence of practice change for example in a report of an intervention design based on partnership nursing assistants who undertook the event were found to be showing slightly but not significantly more personcentred behaviours than students in the control condition 141 the same study reported that residents in the intervention condition had higher levels of satisfaction in their interactions with nursing assistants than did those in the control condition and managers described improvements in job satisfaction and retention of participating nursing assistants 141 in a report that described the extent of multiagency collaboration in the development of the curriculum for care staff and for which the curriculum was developed in conjunction with support workers a statistically significant change was found in the outcome measurements suggesting the likelihood that the intervention changed the way participants performed their jobs 132 in another example in which staff were contacted to get their views on the programme in the development stages 111 it was reported that their work was more cohesive and that they devoted more attention to residents the benefits of consulting with staff about course content pre intervention were noted in a study report of a programme based on the ongoing relationships between nursing staff and residents families 113 in this study significant increases in scores for staff feeling appreciated by families and feeling pleased with conversations with families and in family members being pleased with conversations with staff members were reported contextmechanismoutcome 6 journeying together if the right mix of people are engaged in delivering workforce development programmesinterventions then this can prompt learning together which leads to stronger cohesion across groups and greater understanding of others roles and less duplication and impacts on residents perceptions of care context and mechanism evidence related to engaging with the right mix of people in the delivery of workforce development was noted to provide opportunities for learning together and promote cohesiveness having the right people in intervention delivery could be interpreted in terms of who they are and approaches for learning or journeying together there was also evidence about the different benefits of bringing different groups of staff together to participate in workforce development alongside support workers involving different groups in enabling workforce development several papers referred to internal facilitators drawn from across a service who had distinct responsibility for supporting the delivery of workforce development in a report of a workbased learning programme for direct care workers in assisted living 135 support workers coworkers supervisors and administrative staff took on a training role this was highlighted as a critical component of the workforce development using train the trainers as facilitators had completed a comprehensive programme of education this involvement meant that they were learning as well and each organizations training team begins to develop implementation plans specific to its organization 135 which also links to cmo 4 joining things up around workforce development a programme for hcas working in dementia care which focused on personcentred care used group sessions and reflection to promote learning together 154 the group sessions were facilitated by registered nurses and the pilot study enabled reciprocal learning to take place through facilitator training and also meant that the workbooks presented uptodate knowledge evidencebased practice and real life situations that take place in the wards for patients and staff 154 which links back to cmo 1 making it real to the work of the support worker there is a suggestion that adopting this approach to programme delivery can result in positive outcomes for support workers including personal recognition of the role they play i thought that just being a healthcare assistant i was just a small cog in the machine now i feel i have an important role in the team as hcas spend more time with patients than anyone else 154 in the policing literature we also found evidence to support the beneficial effects of coworkers learning together specifically the potential to increase the relevance and resonance of development opportunities pcsos preferred to shadow other pcsos in their initial training periods and might also benefit from being trained by pcsos rather than police officers who may not fully appreciate the realities of the job for these workers p 4 140 box 6 how journeying together is visible in the interventions included in the review internal facilitators trainers coworkers supervisors administrative staff registered staff credible people patients experts bringing people together multidisciplinary approach working together mutual learning findings nihr journals library we also found that evidence from the education literature supported the finding that undertaking workforce development together prompted learning together 123 as explained in a research report that focused on the management role and training of learning support assistants the opportunities provided for teachers own learning and mentorship promoted staff development and collaborative practice 123 involving different staff groups in supporting the delivery of workforce development was dependent on the degree to which individuals possessed expertise and were able to bring it to bear on the learning 106128131139143150 for example an evaluation of a nursing assistant communication skills programme 120 identified that the commitment and expertise of the social worker were crucial in prompting learning together in addition undertaking workforce development interventions for both support workers and their supervisors prompted learning together in a report of a research study which set out to examine the effects of a relationshipenhancing programme of care on residentcare provider outcomes a threesession educational programme about the dynamics of providing support for care providers was provided for supervisorsmanagers 136 learning together was also supported in interviews in which reference was made to the benefits of undertaking workforce development for both novice and more experienced support workers together because it can prompt sharing and the reinforcement of existing policies and practice because its our policy that when people have a training session the course itself will be populated by experienced carer workers we would not just put a course together or a classroom together of people who are all brand new to care we like to have senior care workers who are updating or refreshing certain topics also a mix of the two because we feel that again its you have the skills and experiences being shared there and also the people who have been working for this organisation can quickly or earlier reinforce that yes the companys policy to do this its policy to do that etc etc and theyll be flagged and highlighted during the training sessions as well so a mixture of experience and new carers is always how we package care training definitely telephone interview participant 3 outcomes in the evidence that we found linked engaging with the right mix of people to deliver workforce development and learning together outcomes related to stronger cohesion across groups 105 and sharing of experience data from interviews also showed that having a good crosssection of people whove got an interest is key to the whole success of the training in a report of a 24hour curriculum for nonclinical direct care workers caring for older people 105 in which different groups of direct care workers undertook the intervention together the findings found that participants expressed increased feelings of worth and belonging p 122 105 there was also evidence to link learning together to less duplication of effort and a greater understanding of others roles impacts on residents perceptions of care and improvements in skills and communication during interactions with residents the explicit use of theory was also important in the translation of learning within workforce development programmes into changes in support workers practice for example in a skills enhancement training curriculum for support workers to improve their problemsolving communication and stress management skills the theory of planned behaviour was linked to understanding how competency development could be transferred from an intervention to their work 132 as it assumes that performance of a behaviour is determined by the individuals evaluation that the behaviour will produce positive consequences 132 there was also evidence of how theories can be applied to illustrate the impact of the work setting on the success of the intervention for example feminist theories and theories of empowerment showing how work issues can be understood in care settings 114 as a precursor to workforce development for example it is important to teach women about the social structures that affect them it is also important to help them understand these structures as well as how they can get involved in and influence their own work situation and work environment 114 development of the support worker evaluation of a training programme aimed at strengthening selfesteem and empowering staff by enhancing their understanding of factors that influence them demonstrated that support workers could influence and improve their work situation the authors indicate an implicit theory underpinning the workforce development in a nursing home setting 114 our presumption was that one way of improving the situation for staff would be to help them develop their selfesteem and feel empowered though a training programme this programme focused on helping participants to understand factors in the work situation that influence them and on empowering them p 835 114 to understand how the support workers could potentially influence their working situation and become more empowered explicit theories from kanter 159 and spreitzer 160 were used and made visible through the homework lesson a way to see problems in a larger context and not to blame oneself thus to strengthen selfdetermination and through participants being encouraged to attend to structures in the organization 114 the stress reduction model was used to frame the exploration of communication and interpersonal caring skills and bereavement in a gerontological training curriculum for care assistants in order to increase professionalism and selfefficacy 138 embedding distinct theoretical approaches needdriven dementia compromised behavior and the progressively lowered stress threshold model 132 in the design of the curriculum made more visible the desired achievement of the programme goal to design a curriculum that helped participants understand in a more comprehensive manner the cognitive changes and physiological changes of their clients 132 potentially melding theories with the goals of the programme would increase understanding about the effectiveness of the workforce development workforce development design there was reference to theoreticallydriven learning strategies considered to be instrumental to intervention design and delivery promoting greater learning about effectiveness of different approaches for example the use of a biographical approach which encourages people to talk about their life and their experiences while enabling the building and strengthening relationships with older people and their relatives 118 outcomes the design of a workforce development intervention to enhance the communication skills of paraprofessional caregivers in dementia care was underpinned by brookers vips model of personcentredness 128 this model incorporated four elements about personcentredness in dementia care valuing people with dementia recognising people with dementia as individuals acknowledging peoples perspectives and promoting a conducive environment to optimise wellbeing for people with dementia v i p and s 128 in this example the model was used as a heuristic to help participants thread together the themes of the programme and their learning utilising the personcentred and hope themes within the model to measure specific outcomes highlighted the impact of the intervention and provided an opportunity for learning about workforce development effectiveness 128 explicit reference to theory was also visible in evaluation reports of interventions that focused on personal development for support workers 144 for example in a report of an evaluation study of an intervention designed for auxiliary and assistant nurses stress theory illuminated the potential of reducing workrelated stress for the support workers through enhancing their control over their work strengthening staff resources of job control work support and learning as well as attaining new coping skills is health promoting p 354 144 furthermore the use of stress theory in a planned approach led to greater potential to demonstrate impact as it illuminated learning about factors that can affect support workers and how they can be empowered summary there was evidence of both implicit and explicit use of theory and planned approaches in workforce development in relation to the development of the support worker contribution to services their personal development and the use of specific learning methodologies the use of theory could be associated with taking a more systematic approach to workforce development which meant that the achievement of learning outcomes was made more obvious within programmes we expect that this is a key requirement for wider programme evaluation and process learning about workforce development contextmechanismoutcome 8 spreading the impacts of workforce development across organisations if workforce development interventions are comprehensive in that they are multilayered and reflect broader developments relevant to the support workforce then this prompts attention to the way in which components of interventions reinforce one another increasing the potential for impacts to embed and spread across organisations box 8 how spreading impact is visible in the interventions included in the review team functioning leadership mentoring supervision organisational factors workplace structure environment culture findings nihr journals library context and mechanism there were some examples of workforce development interventions which demonstrated a more comprehensive approach for example by not only incorporating the individual support worker perspective but addressing their role within groups teams or the organisation as a whole in these cases it appeared more likely that attention was focused on how interventions can reinforce one another this finding was prominent in papers which featured alongside the reporting of the intervention evidence about innovation leadership mentoring supervision and team functioning 112117132133141144154 working through teams some support worker development was nestled within the development of others and organisations as well as themselves with the implication that development at one level is inherently linked to development at other levels this finding was also supported in interview data for example its about being part of the team if you want to be part of this team you have to be able to work to a very good level and um because you know were all were a team here everybodys in the team and i cant work without them they cant work without me thats the same for everybody carers cant work without the kitchen because the kitchen provide all the food for the residents so everybody has to were all as important as one another so were a team telephone interview participant findings in this cmo configuration resonate with journeying together in that bringing the right people together for workforce development was shown to be important to prompt learning together in a number of sources that we uncovered in the review 105136140148157161162 in this cmo the evidence indicates the importance of bringing together people at different levels and from different places in the organisation in and of itself for example in an evaluation of an acute care programme of practice development the authors explained their rationale for bringing people at different levels together for the intervention 161 the overall metaphor for the sessions was of a journey together over a period of time each session had a particular focus which contributed to different stages of this journey and enabled participants to move from being strangers to each other to getting to know each other to working collaboratively p 9 working through organisations in a report of a 1year practice development project set in the context of older peoples care to improve quality of care 163 a sustained and collective approach to supporting the workforce was adopted in the project design to generate a better chances of success for the desired improvements in team functioning focusing attention on the multilayered nature of the system led to an appreciation of how interventions could reinforce one another ongoing work was aimed at implementing cultural and structural changes agreed by the multidisciplinary team supported by research evidence in order to establish new norms of clinical practice and leadership p 340 workforce development drawing on principles of culture change was also evident in an example of a peermentoring programme for support workers in care home settings reflecting the commitment and values of the entire facility the concept of coaching supervision was used to extend the impact of an intervention to improve team working between support workers and registered nurses 141 the project implementation plan introduced the concept of coaching supervision to educate supervisors about how to support staff to solve their issues this approach to the design and development of the intervention meant that in addition to improvements in team functioning reported by managers the impacts extended beyond the participants of the programme to include improvements in nursing care and supportive leadership efforts to demonstrate a comprehensive approach to workforce development were evident in linking elements to the wider context of the organisation this was reinforced in interview data in which we found reference to longerlasting impacts of workforce development if this was focused across the organisation we find that anything to really have a lasting impact its got to be something thats a whole home approach so if were doing something with the support workers we also need to be working separately with the managers with the activity leads and we need to be doing that over a long period of time because otherwise its a limit to how much it becomes an everyday way of working they need to see that other people want to do it that their manager is talking about it in staff meetings celebrating it when theyre doing something thats been a learning from the course and it that only happens if joined up telephone interview participant 6 and so well be making a programme on infection control and well be talking about everything from the kitchen through to the frontline care workers the handy person and the reception staff and getting them all to think about this as how it impacts everybody in the care home equally the condition related programmes again we encourage all the staff from the kitchens and the laundry to come in and watch so that they understand more of the condition that somebodys living with and we find thats very very powerful in terms of spreading understanding spreading tolerance and acceptance also spreading thinking about how best to support people telephone interview participant 6 in the broader context of the organisation in which the support workforce is situated we found evidence supporting linking systemic change management and multidisciplinary approaches in efforts to drive innovation in workforce development 164 particularly in settings in which implementing change is challenging there were also examples of workforce development interventions having a comprehensive focus on workplace structure environmental and cultural factors 113114135157 for example a training programme tailored to one longterm residential care facility was based on the ongoing relationship between nursing staff and residents families 113 a series of workshops for staff were designed for the participants who included personal care assistants senior nurses and their supervisors the role play employed in the workshops enabled participants to experience a range of different situations and to empathise not only with family members but also with other staff members the authors suggest that the development of the intervention highlights the need to consider the range of organisational and systematic factors which can influence the success of similar interventions o ur review has resulted in an explanatory account of how the design and delivery of workforce development interventions work to improve the skills and care standards of support workers within older peoples health and social care services in developing this account we have drawn on a range of evidence including from different public service contexts namely policing and teaching we have generated eight cmo configurations that are explanatory statements reflecting the complexity of workforce development in this setting an embedded stakeholder engagement strategy was used to ensure the interpretive depth and the policy and practice relevance of the emerging findings in this chapter we reflect on the review in relation to our stated aims including l a typology of the workforce development interventions we identified in the literature l a summary of the mechanisms through which interventions work and the contexts that might mediate through an explanatory framework that synthesises the cmo configurations l implications for practice and recommendations for future research typology of workforce development interventions we distilled four types of workforce development from the evidence included in this review which are reported in table 3 this typology is driven by the focus of the workforce development and describes groups of interventions that precipitate changes around different aspects of the support worker role their work environment and the support worker as an individual consequently this typology refers principally to impacts rather than to different approaches to delivering workforce development or the types of changes associated with learning table 3 target of workforce development interventionsprogrammes focus of workforce development characteristics competence workforce development that focuses on the support workers competence in a specific aspect of their work such as monitoring pain assessment and moving and handling 116126135142144149152165 aspects of caring workforce development that targets general caring issues issue of significance to the older person eg dignity health ageing relationships communication endoflife care infection control managing family relationships care planning managing challenging behaviour this may or may not be accompanied by competencebased training 105108111113115120122126128129132 134 135 136 137 138 139 141143152157161 165 166 167 168 169 170 improving team andor service context workforce development that seeks to improve organisational context andor culture and the role of the support worker within it 106107112115122128130133141151152156163171172 personal development workforce development that seeks to enhance the personal growth of the support worker and which may not be directly related to their daytoday work 114132134135143144151166173 however while presenting this in a typology we draw attention to the fact that there is a considerable degree of overlap in the evidence underpinning the classification the evaluations of workforce development included in this review often describe the evaluation of a suite of activitiesinterventions and therefore these types should not be considered mutually exclusive programme theory cumulatively our eight cmo configurations provide a programme theory or contingent explanation which is grounded in evidence from the literature and in stakeholder perspectives about how workforce development works in improving outcomes for support workers organisations and older people although the theory is specific to workforce development for support workers in the context of older peoples services we believe that the cmo explanations are sufficiently abstract to be transferable across other workforce development approaches and service contexts 1 making it real to the work of the support worker if intervention design and delivery is close to the work of the support worker then this prompts resonance with individuals participating in it which can result in cognitive and practice changes in them 2 where the support worker is coming from if workforce design and delivery pays attention to the individual support workers personal and role starting points and expectations then this prompts better engagement with the intervention paying attention to the individual can promote positive personal cognitive and instrumental impacts and potentially impacts for the organisation 3 tapping into support workers motivations if workforce development opportunities include elements of incentivisation then it is likely that participants will feel recognised and rewarded the relationship between incentivisation and having a stake in workforce development can lead to greater emotional and practical participation and engagement with the intervention 4 joining things up around workforce development if interventions are developed in the context of an organisations goals including their human resource and quality improvement strategies then this prompts alignment between the aims of the intervention and the goals of the organisation such that they mutually reinforce each other this leads to a more sustained lasting impact of the intervention reducing turnover and supporting the organisations retention strategy 5 codesign if the right mix of people are engaged in the design of workforce development programmesinterventions then this prompts codesign and a collective view about what needs to be done which can lead to workforce development that is more credible meaningful and relevant for the support worker with greater potential for positive outcomes for practice 6 journeying together if the right mix of people are engaged in delivering workforce development programmesinterventions then this can prompt learning together which leads to greater understanding of others roles and less duplication and impacts on residents perceptions of care 7 taking a planned approach if there is use of theory or evidence of a planned approach in workforce development then this prompts the adoption of a systematic process in its design and delivery which leads to greater potential to demonstrate impact and learn about workforce development effectiveness 8 spreading the impacts if workforce development interventions are comprehensive in that they are multilayered and reflect broader developments relevant to the support workforce then this prompts attention on the way in which components of interventions reinforce one another increasing the potential for impacts to embed and spread across organisations conclusions implications and recommendations nihr journals library each of these cmo configurations is grounded in evidence generated from the review and stakeholder perspectives our starting point in the review for example through the application of soft systems represented workforce development interventions as complex programmes in that they are transformative of people and organisations involve multiple components which affect different types of change at different levels and are mediated by a wide range of political social environmental and other factors we posit that the complexity of workforce development is also encapsulated in the cumulative nature of the cmo configurations that when describing what works in workforce development the whole is greater than the individual contributions of each cmo configuration that is for maximum impact it would be important to pay attention to the features of them all as each cmo configuration includes a different type of contingent change in individual or organisational behaviour or understanding it is inevitable that workforce development programmes draw on a range of theoretical traditions and perspectives some of which come through in the analysis more strongly than others the midrange theories which relate to the cmo configurations identified in this synthesis are summarised in table 4 table 4 illustrative theories relating to cmo configurations cmo illustrative theories implications making it real theories of adult learning these theories pay attention to the different roles and balance of teacherled and studentled approaches to learning for adults the theoretical debate highlights the importance of previous life experiences as a foundation for learning and experiential learning that helps individuals make sense of their learning in terms of application to the realities of work paying attention to the individual expertise in addition to theories of adult learning which emphasise the importance of a participants biography in shaping learning models of skill acquisition also highlight a series of phases which characterise the development of expertise 175 176 177 178 these phases provide an indication of the different understandings of the learning requirements decisionmaking processes and commitment which need to be accommodated in workforce development programmes incentives selfdetermination selfdetermination theory examines the motivations for human behaviour and specifically the roles of both intrinsic and external factors in influencing motivation although there has been some debate about the potential for extrinsic factors such as the rewardbased incentives uncovered in this synthesis a recent metaanalysis indicates that both are important 179 while incentives may be effective in influencing the quantity of appropriate behaviours such as participation in workforce development intrinsic factors may be crucial in ensuring the quality of participation strategy organisational change workforce development programmes operate in a given context in which context or the conditions represent a mix of social cultural and material factors 180 differentiation can be made between the contextual conditions within organisations and external to the setting 181 other conceptualisations of context focus on the interplay between layers of context 182 combinations of experiential aspects of culture leadership and learning climate 183 cmo illustrative theories implications an implication of theorising about context is the important role that context can play in mediating workforce development programme effects and the need to account for context in programme design and implementation 184185 components of context may be considered as driving or restraining workforce development impacts 186 and so provide a focus for planning and tailoring implementation activity 187 codesign coproduction although coproduction is commonly used to describe the process of engaging stakeholders in designing services it is also linked to stakeholder engagement in the processes of knowledge creation and mobilisation 188 as with theories of adult learning there is a recognition of the importance of acknowledging the different forms of tacit and formal codified knowledge that are important which may be brought to bear on a topic in addition different stakeholders bring different priorities and expectations to the design process in workforce development and may draw on and contribute different knowledge bases which cumulatively enrich the learning process and environment 184 learning together interprofessional learning ppi theories of interprofessional learning include the concept of contact in which exposure to others to enable positive attitudes to grow between different groups within the older persons service 190 building on aspects of coproduction the involvement of patient and public stakeholders in aspects of workforce development including in supporting its delivery points to a range of different theoretical perspectives these may involve different explanations of the impacts of involving lay stakeholders in workforce development 191 the evidence in this synthesis relates principally to the ethical dimensions of including service user insights on workforce development challenges using theory programme theory a wide range of approaches to evaluation have a common focus on the use of different forms of theory although these will reflect different ontological and epistemological perspectives regardless of perspective theory plays a key role in articulating the change within a workforce development programme and directing evaluation activity 192 spreading the impacts complexity theory complexity theory focuses on the nonlinear nature of transformative change within workforce development programmes elements of complexity theory include aspects of feedback connectedness and the emergence of new programme elements within this synthesis complexity theory points to the challenges of directing and delivering changes through workforce development in the context of changing organisational and other landscapes and the potential for unplanned change key features of complexity theory that are relevant to the implementation of workforce development interventions include understanding behaviour of the whole rather than its constituent parts that components of interventions and systems interact with each other continually emerge and evolve and that history cannot easily be dismantled and therefore will impact on intervention implementation conclusions implications and recommendations nihr journals library the breadth of more abstract theoretical perspectives pointed to in this review presents a further resource that people designing and delivering workforce development programmes can draw on rarely will workforce development be underpinned by just one of these theoretical perspectives and so different insights from different perspectives are likely to be integrated in workforce development practice in addition they provide an added layer of explanation about why the cmo configurations may operate in the way they do explanatory framework the resulting explanatory framework draws together the key features of the cmo configurations and the relationships between them into a theoretical and potentially practical heuristic to enhance the transferability of the programme theory the explanatory framework has been designed to illustrate the interconnectedness between and across the cmo configurations this was an interpretive task which involved creative processes borrowed from codesign methods and critical creativity 184194 this involved the identification of linking components and representing them in figurative form in this process some mechanisms are now more embedded in the final iteration of the programme theory as represented in this framework the framework represents the starting point or local context mechanisms and potential impacts of workforce development for support workers in its wider implementation context we would argue that the findings of this review have resonance beyond the context of the older persons care setting as they highlight issues relevant to workforce development more generally o r g a n i s a t i o n a l c o n t e x t s k il l s a n d d e v e l o p m e n t care processes a t t it u d e s k n o w l e d g e specifically we suggest that the design and delivery of workforce development needs to take into account the starting points for change these issues form a local or specific context and include l the broader organisational strategy and goalsincorporating what the strategy and goals are and how the development need or gap aligns with the needs and strategy of the older peoples service such as workforce development plans and the adaptation of health and social care policiesprocedures for local needs and ways of working l personal factors about the support workerincluding their personal background career aspirations their existing strengths including life skills development needs values and experience etc l the specific requirements of the workforce development challenge in the context of improving the service for older peopleincluding where the focus for change comes from and the development needs which may be clinical technical behavioural cultural individual team organisational etc in combination these factors provide an initial context in that they determine where they are coming from and therefore if these issues are not attended to in design and delivery they may reduce the impact of the interventionprogramme the comprehensiveness of a workforce development intervention or programme will be determined by systematically considering the starting point of the local context pawson 77 argues for the development of conceptual platforms that represent the basic structure for programmes which can be considered as necessary ingredients of a particular programme or intervention we have found that the design and delivery of workforce development has a greater chance of working or will be enhanced by paying attention to a number of mechanisms the mechanisms include l resonancemaking the interventionsprogrammes components and activities cognitively and emotionally relevant and meaningful to the support workers themselves and to the reality of their daytoday work as carers the evidence would suggest that where these personal cognitively and emotional connections exist there is more personal interest in the development opportunity and greater motivation to engage l alignmentaligning the different pieces of workforce developmentsuch as individual with team and organisation needsrequirements through the use of a planned approach andor theory the evidence would suggest that alignment makes it easier for people to access opportunities there is an obvious fit with their personalrolecareer ambitions and they can more easily apply any learning because it is directed at changes desired by the organisation and recognised appropriately for any achievements l proximityembedding development opportunities and activities with examplesexperiences from the reality of practice including learning being delivered within the workplace there is evidence to suggest that closely aligning learning to the daytoday work may be more effective in shifting from cognitive to instrumental impacts for support workers older people and the organisation conclusions implications and recommendations nihr journals library l learning togetherlearning alongside peers or others that are part of the system to reflect the realities of service delivery learning and development opportunities that provide space for sharing communicating and working on challenges together appear to be successful in building a better understanding of roles and in fostering productive and positive relationships between support workers colleagues and older people l incentivesoffering meaningful intrinsic and extrinsic incentives for engaging with development opportunities and for achieving and recognisingrewarding the attainment of specific goals in this way individual motivation for taking advantage of and continuing involvement in development opportunities can be enhanced l coproductioncodesigning and codelivering development opportunities with relevant stakeholders and participants including residentspatientscarers and support workers themselves taking this approach recognises the different perspectives and therefore contributions different stakeholders will have about the issue incorporating these perspectives provides an opportunity to build a platform for shared learning in addition to increasing the chances of its success because of a sense of involvement and ownership in the process and product review strengths and limitations strengths we consider that the methodological approach used in this review was a key strength as is the intention in a realist review we have developed a theorydriven explanation of how workforce development for support workers might work in the form of eight cmo configurations that make up a programme theory realist review is not concerned with developing statements or recommendations that have statistical certainty about questions of effectiveness or costeffectiveness traditional approaches to evidence synthesis generally rely on a statistical analysis of the findings for example the confidence interval around effect size the philosophical underpinnings of realist reviews necessitate a focus on theoretical depth breadth and transferability it would be inappropriate therefore to produce a quantitative account of the contribution of each cmo configuration within the programme theory however we have paid attention to the weight of the threads of evidence across the programme theory this was an accumulative and deliberative analytical process across phases of the review which we have attempted to document in a transparent way in chapter 2 realist review takes a particular position on how research quality is judged 78195 rejecting the hierarchy of evidence in favour of an approach that facilitated a search for nuggets to help us build up an explanation of how and why a workforce development programme or intervention may or may not work we did not reject evidence based simply on quality in our extraction process we included trigger questions relating to fidelity nuggets trustworthiness and relevance these trigger questions formalised our approach to coming to a decision about evaluating the usefulness of the evidence to the review another strength of this review was the embedded approach to stakeholder engagement including with ppi representatives and in novel ways through for example the use of twitter and a twitter chat adjunct to the study website and blog we operated a twitter account as suggested in a project advisory group meeting which provided a communication channel about the studys topic and fostered additional networking with relevant stakeholders as part of the networking we were invited to lead on a wenurses twitter chat about workforce development for support workers a member of the project advisory group hosted the chat which was useful to elicit the views of the nursing community and inform ongoing discussions the chat also led to networking with practitioners with a vested interest in the topic area a summary of the main points from the twitter chat is provided in appendix 2 this facilitated the development of a credible account while helping us to mobilise knowledge about the work throughout the lifetime of the project limitations in realist terms findings are contingent on there and then conditions from stakeholders perspectives and as reported in the evidence base we acknowledge that decisionmaking at key stages in the review process in this review rests with this unique team and group of stakeholders however we have paid attention to providing a transparent account of our approach in this review including a clear audit trail although we have identified the junctures at which key decisions were made it would be impossible within the confines of this report to provide an exhaustive account of the daytoday decisions we have had to make as part of undertaking the review readers should have some confidence in the fact that the review has been conducted by a team experienced in realist review using an approach to decisionmaking that has been team based as well as a decision logreflective diary we sought additional support for decisionmaking from the wider team in our regular monthly meetings conclusions implications and recommendations nihr journals library we suggest that a limitation of this review is the extent and detail of the evidence that we were able to access as described in our funded protocol we drew on a wide range of evidence to inform the development of this explanatory account including from literature outside of health we had expected given the prevalence of support work roles in other public services that the available evidence base would be larger we used relevant networks and key contacts to ensure that we were not missing any key pieces of evidence and this led to the discovery of some reports these reports and other sources of evidence from these public services tended to be descriptive rather than empirical reflecting on the nature of the evidence base that was included in the review overall we found that reports of studies evaluating workforce development interventions tended to lack detail specifically these reports tended to lack detail about the interventions that were being evaluated for example authors would state that care planning or vignettes were used but did not provide details about these approachestools in addition we found a lack of specificity in reports about what were the perceived and actual intended impacts from the workforce development initiatives being implemented andor evaluated implications and recommendations implications for practice the following implications for the practice of designing and delivering older persons support workforce development interventions are directly related to the eight cmo configuration of the programme theory 1 workforce development programmes should be organised to reflect the realities of the support worker role and work in a number of ways for example i inclusion of material and examples drawn from the reality of practice for example vignettes care planning role playing stories theatre and drawing on the experiences of older people in addition to building on the oral tradition of support workers ii integrating learning within the expectations and boundaries of the role that support workers have such as designing learning opportunities through for example assessments of where the support worker is at in relation to their careerwork ambitions including the ambition of coming to work to do the best that you can today iii bringing learning into the workplace on a sessional or integrated basis this may be more or less relevant depending on the need to access expertise to support learning the availability of a conducive learning environment and whether or not taking the workforce out of the service context may be desirable or necessary to address specific development needs andor to work together with people in different contexts 2 workforce development should be constructed to build on the life skills and experiences that individuals bring to the support worker role and enable role development and career progression for the individual and their organisation this implication is consistent with some of the recommendations from the shape of caring review that development should be appropriately aligned with an individuals skills experience and ambitions some care workers will not have ambitions to progress beyond their current role others will have different career ambitions furthermore individual care workers contribute to their role based on very different life experiences and skills therefore an individual assessment of a persons skills experiences and ambitions will enable workforce development to be designed around an individuals perspective on these issues 3 workforce development should incorporate strategies and techniques that might incentivise and motivate individual engagement in workforce development these strategies and techniques should be designed to address both extrinsic and intrinsic motivators when possible it may also be appropriate to make the incentives as relevant as possible to the support worker to sustain motivation extrinsic motivators should address explicit criteria for attainment for example rewarding the achievement of specific goals such as attendance at learning events and changing behaviours and performance 4 there should be a systematic approach to the design of workforce development which ensures that it is aligned with organisational strategy around for example priorities such as quality and integration across health and social care when this alignment is evident for example by making explicit transparent links in course content and evaluation with the workforce development initiative and other strategies such as quality improvement it should be possible to realise more sustained improvements in workforce knowledge and skills because it should have a cumulative effect beyond the support worker himor herself for example in shared learning events there will be learning and development issues for example improving teamwork supporting individuals transfer of care what is healthy ageing dignity in dementia relationships between staff and families where it would be relevant and promote resonance and to learn among peers involving older people in learning opportunities may be a particularly powerful way to effect changes in value and behaviour for example regarding antidiscriminatory practice and challenging behaviours this also links back to the first implication about making learning meaningful and close to the reality of practice 7 workforce development design and delivery should be approached in a theorydriven and systematic way programme specifications and curriculum plans for example should include reference to and inclusion of relevant theorytheories frameworks and the learning methodsapproachestools used linked to those underpinning heuristics in addition theoretically driven and systematic approaches should be used to evaluate learning and development interventions 8 workforce development should be considered a complex programme that is transformative of people and organisations therefore workforce development should not be ad hoc and fragmented paying attention to workforce development in the context of the whole system which includes individuals teams and the organisation in its wider context is more likely to result in wider and potentially more systemic impacts this will require joining up and aligning various organisational strategies and associated goals such as human resource management organisational development quality and safety and resource management there are more general implications about support worker development which were consistently mentioned by professional and lay stakeholders throughout the conduct of the project these provide a broader context to the delivery of workforce development for this group of care workers 1 support workers make up approximately 60 of the health and social care workforce in the uk 26 2 professional and lay stakeholders consistently highlighted the importance of investing in the support workforce as a firm foundation on which to improve the quality of health and social care while recognising the importance of being clinically competent they also stressed the importance of some fundamental aspects of service delivery including dignity compassion and communication therefore workforce development opportunities need to balance the technical with the professional and emotional aspects of caring work with older people conclusions implications and recommendations nihr journals library related to implication 2 investment in the development of the older persons support workforce provides a visible and clear recognition of the value attached to the contribution of support workers our evidence identified the use of some incentives to encourage participation with and engagement in workforce development however there was little evidence of a joinedup approach to a workforce development in this context which linked learning with opportunities for career development personal growth and monetary and other rewards for skill and role development recommendations for future research our recommendations for future research relate both to aspects of research methods and to the further evaluation and explication of our programme theory with respect to research methods the synthesis demonstrated generally poor reporting of workforce development interventions in future research we recommend that l the typology proposed in this synthesis could be used to describe the focus of the intended workforce development l authors provide clear and detailed description of the component of the intervention including the theory of change for the workforce development intervention being clearly reported this will make the ongoing synthesis of evidence around workforce development easier to manage and provide opportunities for learning and improvement methodological recommendations we have reflected on the processes we used to apply the principles of the particular methodological approach for this review and suggest some recommendations for future use of realist synthesis as an emerging approach for research inquiry in particular we recommend that realist synthesis should be considered for future work to explain the intricacies of programme such as workforce development the focus on theory development at midrange level provides practicable guidance for providers commissioners and users of workforce development we have suggested that the design and delivery of workforce development has a greater chance of being successful if attention is paid to the mechanisms which represent the basic structure for such programmes in this review we found that the combination of desk work and active stakeholder engagement was a good framework for identifying key mechanisms and recommend that future realist studies build on the specific approach that we undertook future application of realist methodology can draw on the account that we have provided of the approach and work conducted throughout this review using the tools and processes used andor developed our tools include a living document to log decisions and reflections and a set of constructs within the data extraction form to guide decisionmaking soft systems methodology guided our understanding of factors which we found can influence the success or otherwise of workforce development at a system level our engagement processes included additional support for decisionmaking from the wider team in our regular monthly meetings and active engagement and communication with stakeholders and ppi representatives through for example workshop group work glossary website blog and use of social media although pawson offers principles to guide the analysis process in realist synthesis it is not suggested that these be used prescriptively we chose the abductive analysis of evidence in this review as it reflects the realist quest to elicit generative mechanisms that explain the contingent nature of phenomena we considered that retroduction was appropriate for this review as we could draw from a wide range of experience and expertise we suggest that future research develop and build on these and other approaches for analysis to ensure that realist researchers can access resources and guidance that reflects their particular research aims and objectives conclusion this ◢ ▮ ▮ ▮ ▮ ▮ ▮ ▮ ▮ ▮ ▮ ▮ ▮ ▮ ▮ ▮ ▮ ▮ ▮ ▮ ◢ ▮ ▮ ▮ ▮ ▮ ▮ ▮ ▮ ▮ ▮ ▮ ▮ ▮ ▮ ▮ ▮ appendix 1 nihr journals library t he chat host used her personal experiences with a care assistant colleague who had influenced her own practice to kickstart the discussion which led to many personal recollections among the twitter audience about their own experiences of working alongside care assistants individuals who made lasting impressions were those care assistants who demonstrated qualities such as kindness humility and respect promoting compassionate care and commitment examples of care assistants showing good organisational skills were shared and other commendable attributes were considered to be care assistants abilities to teach others about essential care supporting the nursing team in different ways including increasing registered nurses confidence levels one comment highlighted how care assistants are perceived to have a pivotal role in the patients journey and others see the care assistant as the glue for team working and the eyes and ears for wardsin this way the roles are described as good barometers for care audience members agreed that although care assistants are vital members of the team they can also be underestimated moving to the questions relating to role development the twitter audience had clear views on making training relevant to practice and one comment suggested that for care assistants delivering training should be through their eyes the principles of training and development should be the same as for other staff groups so understanding individual learning styles was considered to be important so that training can accommodate different needs the quality of training was discussed and views on content included teaching listening skills to promote empathy with patients and delivering training in different ways the main focus should be on developing relationships audience members had experiences of care assistants wanting more training than that offered however for others there was recognition that additional training and development beyond refreshers may not be desired sometimes care assistants may not want additional training but still want to be respected for doing their job well practical teaching and supervision peer support supervision and valuing their role as teachers for other care assistants were discussed as important ways to develop individuals career pathways for care assistants was a hot topic perceived by some as important so that individuals can flourish promoting their talent and skills and possibly linked to nursing registration and retention however it may not be the approach for all whatever the route care assistants choose to take in their career equal opportunity is important the importance of celebrating care assistants achievements was discussed vigorously linked to awards and recognition events care assistants should be able to be involved in decisionmaking to voice their opinions and influence change and to access leadership training if they wish in terms of care assistant development there is a need to recognise the impact of changes and developing skills on efficiency and patient care experiences team working to promote quality of care is key managerial support important to reduce the potential risks associated with devolving responsibility for assessment of competency in the skills required to deliver fundamental care from registered nurses to unqualified staff 164 there were challenges for developing support workers entering longterm care services where a focus on innovation is driven by policy and academia so a mismatch between training and reality was found the link between systemic change management and multidisciplinary approaches was considered essential to drive innovation in longterm care settings aubry et al it implementing change in ltcos remains a complex task that is often based on intuition and anecdotes and characterized by very uncertain outcomes p a strategic analysis approach was employed to understand the relationship between the development of nursing assistants in longterm care services and the organisational context and how this relationship impacted on developing change management strategies croziers framework makes it possible to define the means of understanding the collective structure of the nursing assistants work during the many change endeavors facing ltcos as described below in the study findings p challenges and constraints can lead to homogeneity among nursing assistants that they develop strategies and discussed how these are shared with new staff the papers findings suggest that using informal practices and team working can facilitate change overlooking the potential input of nursing assistants in the development of an innovative care program or else soliciting the input of an individual nursing assistant rather than that of the team can foster resistance to change p braun et al 105 based around homecommunity healthcaredirectcare workers with older people in the usa in nonmedicare ageing network suggested identified gap in nonclinical trainingeducation our goals were to provide a foundation for nonclinical direct care workers by imparting a basic knowledge of aging improving assessment and reporting skills increasing empathy for older adults teaching strategies to manage stress and validating the importance of direct care workers p disjointed approaches can lead to lack of meaning for directcare workers direct care workers in this study had relatively few years of education and little knowledge of basic aging processes differential effects of aging and disease and good selfcare principles many conceptualized their jobs as custodial rather than therapeutic and did not see the value of their work p caring for themselves can impact on the care that directcare workers provide for older people the degree of control directcare workers had on their development and practice influenced the success of the intervention another probable reason for success is that we focused on improving basic knowledge and attitudes that were under the control of the direct care worker rather than on teaching clinical behaviours that may require concurrent organisational or systems change p appendix 10 133 reported how a notforprofit organization was supportive of the project in one longterm care setting in the usa the author linked peermentoring programme to improving culture change as it had the potential to improve the retention of staff when turnover staff was high which also ultimately reduced costs for the organisation peer mentoring is alsoin itselfa way to create a culture of caring among aides within a longterm care facility when carefullyselected experienced cnas who embody the caring values of their facility become successful peer mentors there are clear potential organisational changes p cnas who demonstrated a culture of caring were recognized for this thereby increasing their own satisfaction the behaviours and attitudes the new cna is exposed to making it more likely they will be the traits which are learned and emulated p 29 hockley 115 report of action research about how to develop strategies to develop quality care in nursing homes time constraints low morale and need to develop a culture of learning were identified as work factors experiencebased learning was considered to be a way to draw out the ways in which people learndidactic experiential critical thinking highlighted the importance of the provision of support and learning for care assistants care assistants play an important part in end of life care because they have often cared for the resident for many months even years they can feel excluded when nurses take over the care when a resident is dying p morgan and konrad 141 the ratings of perceived career rewards improved for participants who completed a specific programme in north carolina nursing homes 135 direct care workers in assisted living in oregon found that a focus on the environment is significant to successeg investment in supervisors organisational policy changes made to support trainees in addition to the content targeting al workers the results of this study offer additional support for a workbased learning design for frontline workers the emphasis on oneonone and small group learning provides a structure for engaging and supporting all levels of staff both as trainers and learners p clarke et al 118 describes the findings of a developmental study undertaken over a 6month period to investigate the introduction of a biographical approach to care on a unit in one nhs hospital in the uk the focus of the study was on the experiences and views of older people and practitioners working in the field practitioners were central to the research process and were involved throughout the planning delivery and dissemination of the study p mclellan et al 145 describes how a new interprofessional primary care practice team was defined and how it implemented a new appraisal system drawing on the principles of 360degree appraisal in order to support and reinforce positive and responsible interprofessional team working take into account the concerns and requirements of both the team members and the service organization embrace the appraisal requirements of different professional groups and partner organizations p it was suggested that the appraisal system could complement existing organisational systems these included short monthly onetoone meetings between the service development manager and each team member to discuss workload performance and development and also team discussions about roles responsibilities values team policies and service developments p 46 parry and vass 197 discussion about some of the issues relevant to the role and training of physiotherapy assistants process of role definition assessment and training of an individual developed in the context of a larger research study points about assuming capabilities and importance of supervision are reflected in interviews with physiotherapists expectations and knowing staff were mentioned as important by several participants as was the need to give assistants responsibility and a role within the team level of supervision depends on competence and experience its a professional judgement they need to have a feeling of positive contributioninvolvement in decision making p 147 hca role in general practice progression acknowledgement of the role and how personal characteristics sometimes influence development the report emphasised the importance of recognition and the environment for role development and showed some negative attitudes about the role vail et al although the three youngest hcas were positive about their role and claimed to enjoy it they spoke more often about negative aspects of the job such as low pay and the lack of opportunities to progress p appendix 10 shed some light on the perceived status of hca role as illustrated by these quotes over half of the hcas commented on their role being of minor importance within the gp team the interviewees often referred to their tasks as menial silly and mundane and implicitly or explicitly compared them to the more important responsibilities of the nurses p 35 i think i take the pressure off the nurses because i can do little jobs for them which means that they can move on and do other things that are more important p 36 obviously im not allowed to give injections and do smears and that but just silly little things like doing a leg dressing or stitch removal p 36 practices therefore need to ensure that their wider workforce is fully prepared when taking on an hca for the first time hcas in this study appreciated their colleagues support and encouragement on both a daytoday basis and also in relation to role development p 39 evidence source theory area 1 fit with career development policy strategy and structures weekly team meetings were seen as essential in helping to engender cohesion and provided the forum for much of the above discussion however one support worker noted that things could be improved if attendance at team meetings was made mandatory p support workers stressed that the ready availability of more senior colleagues was pivotal to them feeling well supported especially at difficult times this fostered a feeling of security amongst the staff team as well as contributing to a thorough assessment of risk p it was not just immediate managers who valued the contribution of the support workers since senior personnel within the national health service trust were also perceived to value the service and support the workers contribution to it p these data exemplify the significance of being valued by fellow colleagues and senior managers of feeling protected from potential overwork and emotional harm this was essential because the support workers were relatively autonomous in their daytoday work which was another major factor contributing to their feelings of job satisfaction p bailey et al 173 insight into the emotional labour of the hca role with the concept of detachment being viewed as positive for engagement as opposed to being perceived negatively ideas for teachingsupervision the concept of detachment is perceived in a positive light offering case studies to illustrate points this presents detachment as an active emotional choice a putting aside of certain feelings in the interests of completing ones job as we also observed this does not mean that detachment may not in some cases indicate a disinterested or uncaring attitude on the part of hcas p insight into organisational responsibility for the development of support workers to negotiate the complexities of their patients needs dispositions and communication abilities while also delivering the practical aspects of good care demands a high level of emotional output and superior skills in selfregulation which are littlerecognised characteristics of the role of hcas p ideas about training and supervision hcas must be given the space to reflect on the relationship between thought and action in their everyday encounters with patients therefore we suggest that developing a model of supervision along the lines of qualified nurses clinical supervision which is delivered by someone outside the ward could greatly benefit hcas p data sharing statement all available data can be obtained from the corresponding author health services and delivery research editorinchief professor jo rycroftmalone professor of health services and implementation research bangor university uk nihr journals library editorinchief appendix 2 wenurses twitter chat summary 23 summary there is evidence to suggest that if different groups of people are engaged in delivering workforce development interventions then learning together can lead to greater understanding of others roles and potential impacts on residents perceptions of care the ways in which journeying together was made visible included through the use of internal facilitators and credible people and by bringing people together through joint sessions contextmechanismoutcome 7 taking a planned approach in workforce development if workforce development draws on theory or there is evidence of a planned approach then this prompts the adoption of a systematic process in its design and delivery which leads to greater potential to demonstrate impact and learn about workforce development effectiveness context and mechanism in this configuration we were able to trace an evidence thread around the impacts of a clearly articulated predefined theoryplanned approach and a more systematic approach in the design and delivery of workforce development we found explicit references to the use of models 112128132133155 theories 112113132136144 and frameworks 115136 155 156 157 linked to the methods then used 132153156 in three key areas 1 the development of the support workforce contribution to services 2 the individual support worker himor herself 3 the delivery of workforce development itself improving services there was a wide range of evidence referring to the use of systematic approaches to workforce development for service quality 112115136155157 for example we found a report of using informed teams in care home settings 112 informed teams is described in the paper as a staff development programme which integrates skills in routine practice with staff development to meet staffs needs in this paper lawton and nahemows 158 1973 theory of competence and environmental press was applied to staff development activities that address staffpatient needs in an attempt to understand the characteristics in nursing home context recognising that behaviour and affective responses are functions of peoples personal resources although the theory describes older adults adaptive behaviour it is also applicable to nursing home staff members in the context of the nursing home work environment p 246 112 box 7 how taking a planned approach is visible in the interventions included in the review models theories frameworks methods findings nihr journals library outcomes the evidence shows how factors related to team functioning and organisational factors can enhance the potential for impacts to spread across organisations in the papers in which we uncovered evidence about team functioning examples of impacts that could be embedded included better management of challenges by staff 105 changes in job performance 132 and improved ability to demonstrate empathic and reliable behaviours and relational care 136 from the evidence in papers which highlighted organisational factors we found that outcomes related to supporting staff and improving retention 133 supporting leadership 141 and improving quality of care 163 there is also evidence to suggest that particular interventions such as ongoing supervision mentorship and coaching can promote longerlasting impacts 109117 we found limited examples of wholesystem approaches to development the exception to this would be practice developmenttype programmes 163 this intervention works at multiple levels and in doing so has the potential to lead to impacts at an organisational level which could last longer than oneoff interventions aimed at the individual support worker summary workforce development programmesinterventions that are comprehensive have the potential to prompt attention to be paid to the way in which interventions activities reinforce one another this approach could lead to the potential for embedding workforce development and scaling up so that the impact is felt across organisations scaling up is made visible through evidence that shows team functioning features and when attention is paid to organisational factors chapter summary the cmos presented in this chapter highlight evidencebased statements of what works in the development of the older persons support workforce these have been presented individually to enable understanding in practice these are integrated and interactive highlighting the idea of workforce development as a complex intervention or programme we include a figurative representation of this complexity in chapter 4 contributions of authors professor jo rycroftmalone was the coprincipal investigator coled the study design was involved in all aspects of the review process and is colead author of this report professor christopher r burton was the coprincipal investigator coled the study design chaired the monthly research team meetings facilitated the advisory group and stakeholder group meetings was involved in all aspects of the review process and is colead author of this report dr lynne williams took daytoday responsibility for project management and for the review process cofacilitated stakeholder and advisory group meetings was involved in all aspects of the review process and coled the preparation of this report mr stephen edwards was a lay research team member he participated in monthly meetings provided feedback and input in between meetings prepared a glossary of terms and participated in the preparation of the final report mrs denise fisher was a lay research team member she participated in monthly meetings provided feedback and input in between meetings prepared a glossary of terms and participated in the preparation of the final report dr beth hall was a coapplicant on the grant was involved in study design was involved in monthly research team meetings led the information searching retrieval and organisation gave feedback in between meetings and participated in the preparation of this report professor brendan mccormack was a coapplicant on the grant was involved in study design involved in monthly research team meetings gave feedback in between meetings and participated in the synthesis process and in the preparation of this report professor sandra nutley was a coapplicant on the grant was involved in study design and monthly research team and stakeholder meetings gave feedback in between meetings helped to sift evidence within the context of education and participated in the synthesis process and in the preparation of this report dr diane seddon was a coapplicant on the grant was involved in study design and monthly research team and advisory group meetings gave feedback in between meetings and participated in the synthesis process and in the preparation of this report theoryarea questions l what impact does career development have on outcomes for the workforce l how do the ways in which support worker roles and personal development are met through workforce development impact on outcomes l how do organisational and work factors mediate on the outcomes for workforce development services and older people and their care providers l how do the means in which workforce development interventions are streamlinedconnected impact on outcomes for the workforce service and older people and their care providers l what is the impact of support worker roles being promoted as a positive career option 2 effective workforce development is designed using flexible interactive experiential approaches and implemented and evaluated in close proximity to the work of the older peoples support workforce and practice programmes or interventions that are neither grounded in the reality of daily work completed by the older peoples support workforce nor delivered within in the workplace are less likely to be effective theoryarea questions l how does the location of workforce development impact on outcomes for the workforce delivery of services and older people and their care providers l how does the flexibility in delivery of workforce development interventionsprogrammes impact on outcomes l how do educational models and styles impact on the outcomes for workforce development l how do the ways in which support workers are involved in setting the workforce development agenda impact on the development of support worker roles 3 effectiveness can be mediated by the personal characteristics of members of the older peoples support workforce practice development aspects of human and social geography characteristics of the organisations in which the support workforce are operating workforce and service policy and public experiences and expectations theoryarea questions l what impact do the people involved in the design and delivery of workforce development have on the outcomes for the workforce service and older people and their care providers l how does workforce development enhance the public perception of support workers roles l how does the role of personal and other characteristics of the workforce influence workforce development outcomes l how do leadership styles impact on the outcomes for workforce development l what is the impact of policy on the outcomes of workforce development for the workforce services older people and their care providers l how do strategies for commissioning validating accrediting and quality assurance impact on outcomes for workforce development services older people and their care providers l what is the impact of multicultural issues on the outcomes for workforce development in this context l what is the impact of gender issues on the outcomes for workforce development in this context the effectiveness of workforce development interventions and programmes for the support workforce for older peoples services can span outcomes for the workforce the delivery and quality of services through organisations and for older people and their families care providers interventionsprogrammes are most effective when positive impacts from workforce development can be identified in all the above areas when these impacts do not meet the expectations of older people or health and social care organisations then positive individual changes from workforce development programmesinterventions might be evident andor achieved but not sustained theoryarea questions l how do workforce development interventions balance core and specific skills for the support workforce for older peoples services l how do programmes instil and encourage confidence in the support workforce to contribute to quality improvement 151 suggestion that career development for hcas is best promoted through using a phased approach to cpd and progression and linking national strategy to frame design the training and development pathway incorporates three phases of continuing professional development the essence of care programme and nvq care levels 2 and 3 these enable hcsws to develop skills and achieve recognition of these skills with the opportunity to progress to nurse training p 34 suggestion that the academic gap is addressed through linking with a study skills module as integral part of developmental pathway for hcas based on collaboration with heis and discussions with student nurses who had completed the nvq route the benefits of a structured approach to progression in an nhs trust discussed and use of manager nomination model for progression to the next level implementing a structured approach to the training and development of hcsws ensures gradual development in both theory and practice it also enables hcsws to plan their professional development and identify a career pathway p 37 owing to the organisations policy of employing large numbers of hcas consistency issues emphasis made on linking with partners to deliver training programmes and highlighting the importance of organisational commitment to develop competency for healthcare support workers support for hcas is often reliant on the support they receive from their peers in practice few qualified nurses in place as assessors because of work demands led to healthcare support workers becoming the assessors it was apparent from discussion with hcsws that much of their support in practice came from successful nvq care candidates who had experienced the process first hand this suggested that there was the potential for hcsws to train as nvq care assessors p 35 evidence source theory area 1 fit with career development policy strategy and structures 17 noelker et al 196 lack of training for supervisors in care settings in ohio usa and also continuing education more than half the supervisors said their continuing education either did not cover or was not helpful in improving their abilities to do the following demonstrate good leadership handle racial issues in the workplace motivate staff manage insubordination and deal with difficult workers p 94 other factors were considered to be important for targeting to improve workplace support the positive effects of peer mentoring at hire and having job orientation and continuing education programs that workers view as adequate for their needs suggest these programs should be given more careful attention in efforts to improve satisfaction with supervision p 98 petterson et al 144 study set in nursing homes in sweden and the report referred to the use of stress theory to plan interventions in order to support strengthening staff resources of job control work support and learning as well as attaining new coping skills is health promoting p 354 the intervention was introduced as an empowerment project for care assistants job control is defined as learning authority and authority over decisions by increased job control and support the selfconfidence of employees is enhanced stimulating their engagement and activity p 356 the project has inspired new efforts on professional authority and career development for auxiliary and assistant nurse advancement opportunities have been created for these nurses by a recently permanent stepwise career ladder which serves as a model for care organizations in other municipalities in sweden and has attained international attention p 367 paraprofessional training for staff working with older people in the us context the paper includes reference to the significance of the organisationalmanager role of reinforcement by reinforcing paraprofessionals strengths and worth trainers convey the impact and the process of building on strengths this skill can then be applied by trainees in recognizing the worth of during the course of their work p 86

improving skills and care standards in the support workforce for older people a realist synthesis of workforce development interventions health serv deliv res 20164 12

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abstract the largescale international migration in the 21st century has emerged as a major threat to the global health equity movement not only has the volume of migration substantially increased but also the patterns of migration have become more complex this paper began by focusing on the drivers of international migration and how health inequalities are linked to migration situating migration within the broader structural contexts the paper calls for using the unharnessed potential of the intersectionality framework to advance immigrant health research despite coming from poorer socioeconomic backgrounds and facing disparities in the host society the immigrants are often paradoxically shown to be healthier than the native population although this health advantage diminishes over time studies on immigrant health however are traditionally informed by the acculturation framework which holds the assimilation of unhealthy lifestyles primarily responsible for immigrant health deterioration diverting the attention away from the structural factors although the alternative structural framework came up with the promise to explore the structural factors it is criticised for an overwhelming focus on access to healthcare and inadequate attention to institutional and societal contexts however the heterogeneity of the immigrant population across multiple dimensions of vulnerability demands a novel approach that can bring to the fore both premigratory and postmigratory contextual factors and adequately capture the picture of immigrant health the paper concludes by questioning the acculturation perspective and pushing the structural paradigm to embrace the intersectionality framework which has the potential to address a wide range of vulnerabilities that intersect to produce health inequalities among the immigrants introduction there has been a dramatic increase in international migration over the last two decades and it is continuously on the rise in an increasingly globalised context with substantial implications for population health policy and research the number of international migrants was estimated to be 272 million in 2019up from 244 million in 2015 1 while a negative view towards immigration is growing at a global level with people in many destination countries especially in europe and america preferring to decrease their current level of immigration 2 the number of international migrants is projected to reach a staggering 405 million in 2050 and the current rate of increase has even surpassed the previous projection due to the largescale displacements occuring globally in most recent years 1 the forces of globalisation economic pressures climate change and environmental degradation political violence and human rights abuses are said to be the major drivers of this unprecedented human mobility worldwide 1 3 if the international migrants were to comprise a nation state it would be the fifth largest country on the planet in terms of the size of the population although human mobility is not a new phenomenon the rapid increase of the worldwide migration flows in the contemporary world has no precedence bmj global health in human history not only the migration flows that have substantially gone upward but also the patterns of migration have themselves become more complex and diversified over time necessitating an increased attention to the determinants of migration while the lives of the immigrants are shaped by social economic and political structures policies and institutions in their homelands they experience new sociopolitical and economic conditions in the countries of destination where they live under discriminatory policies and often lack access to critical health resources 4 migration is thus accompanied by enormous consequences on the daily lives of the people who migrate and is often shown to be negatively associated with adverse health risks and outcomes 5 6 however most studies examining the association between migration and health tend to overlook the immigrants migratory experiences and background circumstances from the country of origin 7 this is a serious cause for concern since any association between a postmigration experience and health might theoretically be confounded by the events experienced prior to or during migration drawing on existing literature the current paper aims to ► provide an overview of the major forces that drive the crossborder population movements and how health inequalities are shaped by the structural processes of immigration and marginalisation ► present a critique of the two theoretical frameworks that are commonly used to explain the health status of immigrant populations the cultural framework and the structural framework ► highlight the potential of the intersectionality framework to better document and understand immigrant health what drives migration internationally the dynamics of population movements are quite complex and varied the key issues are whether such movements are internal displacements or crossborder movements whether the decision to migrate is forced or voluntary and whether migration takes the form of temporary circular or permanent movements 8 whatever the type of migration is the core choice involves calculating the risks and benefits of moving versus staying and the ultimate decision to move may be influenced by a wide range of economic social demographic political and environmental factors which include improving income and standards of living pursuing quality education getting reunited with family members escaping political persecution and getting rid of environmental threats none of these factors however act in isolation they tend to operate in combination with each other also the effects of these factors on migration are likely to be confounded by the migrants personal circumstances such as class ethnicity religion language cost of moving social networks and the immigration laws 9 10 as migration has emerged as a global phenomenon at the turn of the 21st century globalisation provides the key context for understanding the international migration flows while globalisation is said to be positively associated with overall economic development further bringing with it a variety of social political and health benefits 11 the benefits are disproportionately distributed across national borders this asymmetrical character of contemporary globalisation exacerbates social and economic inequities both between and within countries 12 international migration can be seen as a reflection of global inequalities between countries to the extent that migration is primarily driven by economic incentives global income inequality serves as a major push factor that motivates people to emigrate in order to look for opportunities elsewhere as black and colleagues 13 have so aptly put it international migration is a powerful symbol of global inequality whether in terms of wages labour market opportunities or lifestyles millions of workers and their families move each year across borders and across continents seeking to reduce what they see as the gap between their own position and that of people in other wealthier places today globalisation has made international transportation and communication much faster and easier than ever before as a result not only has the scale of international migration accelerated but also the character of migration flows has altered substantiallyfrom the typically permanent migrations of the past to the circular or temporary migrations in current times 14 15 in concert with the accelerating pace of globalisation processes climate change or environmental degradation has emerged as a leading trigger factor of migration in recent times and is predicted to give rise to even greater population movements in the coming years by the middle of the current century the number of environmental migrants both internally displaced and international is estimated to reach as high as 250 million 8 a figure which outnumbers the current stock of international migrants throughout human history migration has always been an important adaptation strategy in response to adverse environmental conditions whereas the internally displaced people constituted the vast majority of environmental migrants in the past the volume of international movements is of increasing significance 16 moreover in contrast to the historical experience of mass displacements resulting from natural environmental disasters today the world has started witnessing a new trend of population movements due to humaninduced climate change global warming and its inevitable productthe rise of sea levelsis the predominant feature of this climate change which is primarily driven by humangenerated emissions of greenhouse gases however climate change itself may rarely be directly linked to international displacements but is likely to exacerbate the existing vulnerabilities and generate slow onset environmental effects which in turn may affect bmj global health the livelihoods of people their migration behaviour and health and wellbeing 8 immigration othering and health inequalities othering is a process that effectively sets up a distance between us and them and the individuals positioned as the other experience this as a process of marginalisation disempowerment and social exclusion 17 viruellfuentes 18 points to the potential pathways through which othering might affect the health of the immigrants and their descendants viruellfuentes argues that othering is a function of structural racism and as such contributes to the shaping of the ethnicracial status of the immigrants this in turn influences the more proximate pathways to health including stress fear experience of prejudice and violence access to healthcare safe work and housing consequently the immigrants are more likely to be unemployed work in low paid jobs end up in low status neighbourhoods and report poorer health than the native population 5 while all migrants might be the victims of the othering process the forced migrants such as the refugees asylum seekers and irregular migrants are more likely to experience it than voluntary migrants grove and zwi 17 highlighted how the forced migrants are constructed as the other in their place of destination and are systematically set apart from the mainstream society forced migrants typically flee away from countries where access to healthcare is limited and exposure to illhealth is substantial each stage of the journey of forced migrantspredeparture travel arrival and returnis accompanied by health hazards their journey to the host country is often dangerously prolonged and marked by an ongoing fear of uncertainty anxiety insecurity separation from family exploitation lack of food and shelter sexual abuse violence injury and even deaths 19 these prior exposures of the migrants are further exacerbated by the process of othering and have profound implications for immigrant health and wellbeing refugees and asylumseekers are rarely perceived as the carriers of skills and capacities to the new society they are rather perceived as a threat to national security and vectors of infectious diseases which in turn leads to a focus on the protection from the refugees instead of protection of the refugees this is clearly reflected in the complex security measures including heightened level of frontier control restricted visas screening deterring detention and so forth 17 even when the migrants are welcomed the fear of repatriation and concerns about future safety and security persist empirical evidence suggests that the sustained periods of severe stress before during and after the migration leads to the development of mental illnesses including depression and posttraumatic stress disorders 5 this is particularly problematic for the undocumented migrants who remain excluded from the health welfare and social services for a prolonged period of time moreover the vulnerability to illness due to the structural process of othering may be further compounded by the background characteristics of the migrants putting certain groups of migrants at greater risks than others 3 majority of the existing body of literature linking migration to health lend support to the socalled healthy immigrant effect hypothesis which postulates that the health of immigrants is significantly better in comparison with their native counterparts in terms of mortality chronic diseases and mental health outcomes 6 2029 such a pattern of health appears to be paradoxical given the relatively poor socioeconomic background of the immigrants as well as the socioeconomic disparities they face in the receiving country the healthy migrant effect is typically attributed to the process of selective outmigration 22 23 30 a further hypothesis proposed to explain the lower mortality among immigrants underlies the concept of salmon bias which suggests that the socioeconomically unsuccessful immigrants with a higher risk of mortality have a tendency to return to their home country leading to an underestimation of migrant mortality in the host country 31 32 33 the reported health advantage of the immigrants however does not usually persist over time several studies for instance indicate that the immigrants living for several years in the host country have worse health than the newly arrived immigrants or the native population implying an erosion of immigrant health over time and across generations 20 2528 34 traditional theoretical approaches to immigrant health the cultural framework while the literature provides evidence in support of an initial healthy effect and a subsequent decline in health the mechanisms underlying this health transition are still poorly understood the most dominant explanation typically comes from the cultural framework that views culture as the primary determinant of individual level health behaviours according to this view culture impinges on health outcomes via influencing social networks and individual health behaviours as the immigrants arrive in a new society they abandon the cultural practices of their country of origin and quickly adapt to those from the host country leading to a progressive deterioration of their health status 35 central to the cultural explanation is the concept of acculturation an individual level process in which immigrants take on the culture and habits of the mainstream population to the extent that this process influences health risk behaviours acculturation is negatively associated with health 4 the acculturation approach is often critiqued to be empirically deficit since it loosely defines and operationalises the variables of culture also it holds an ethnocentric view by assuming a mainstream culture toward bmj global health which the immigrants or minority groups are presumed to be acculturating 4 moreover a core criticism against the acculturation model is that it takes a victimblaming approach by putting the onus on the individuals in this approach culture is seen to be embedded within the individual rather than a socially constructed system 18 and hence the responsibility of adopting healthy cultural practices lies with the individual studies based on the acculturation framework therefore divert the attention from the structural factors for example access to healthcare and differences in labour markets and obscures the role these factors play in the unequal distribution of health outcomes among the immigrants the structural framework there has increasingly been a shift in focus from the popular acculturation framework to a structural framework that aims to consider the role of macro level social forces in producing and reproducing health inequalities among the immigrants current research using this framework tends to focus on access to healthcare or the barriers to accessing healthcare and on health outcomes directly linked to migration status or the living and working conditions of the immigrants access to healthcare has been the most common structural factor explored in the literature 36 37 38 although access is considered to be a downstream product of a wider sphere of upstream structural conditions 4 39 the exploration of other institutional and social contexts is relatively limited and mostly concerns the circumstances in the host society while the countryoforigin circumstances are often overlooked only a few studies have attempted to explicitly assess the role of the premigratory conditions in the postmigration health trajectories 7 34 43 based on panel data from 19 european countries the study by bousmah and colleagues 34 reveals that while the health of the native and foreignborn populations converges over time there is substantial effect heterogeneity depending on the wealth of the countries of birth corroborating this finding an american study concludes that the level of income inequality at the place of birth negatively affects postmigration health trajectories independent of the national income and life expectancy at the countries of origin 7 modern theoretical approaches to immigrant health the social determinants of health framework the social determinants of health approach shifts the focus from the downstream factors to the more upstream causes of the causes in the causal pathways influencing health 39 44 some scholars are arguing for using the untapped potential of the structural framework within the sdh framework that acknowledges the role of social and policyrelated factors in shaping individuals lives and how these factors operate to exclude certain groups and communities not only from medical care but also from various health promoting resources 4 45 although the wholed sdh agenda is an important development to this end 46 47 it does not specifically identify migration as a social determinant of health and is criticised for its overwhelming priority on the health gradient in relation to socioeconomic class at the expense of migration ethnicity and other categorical determinants of health gaps 48 however migration itself serves as a major source of social stratification and substantially contributes to the patterning of health inequalities by influencing other spheres of social life in the sdh framework migration is viewed as both a consequence of social determinants such as poverty unemployment living conditions and access to social services and a powerful social determinant affecting all of these areas 4 positioning immigration as a key social determinant of health the sdh approach seeks to explain the health outcomes of immigrants as a function of their social contexts in which they are born grow live work and age 46 the intersectionality framework intersectionality is a powerful theoretical approach that aligns itself with the structuralsdh framework and offers important insights into the social structures of power and exclusionary practices since the conventional structural and cultural frameworks have limited utility in explaining the multifactorial health disadvantages in the immigrants intersectionality is now acknowledged as an alternative theoretical perspective that can bring to the fore both premigration and postmigration contextual factors complicating the picture of immigrant health originated from black feminist and critical race thoughts 49 50 intersectionality has the goal to empower those who are multiply marginalised kimberle crenshaw a legal scholar and black feminist theorist is credited with having introduced the term intersectionality in her groundbreaking work in 1989 49 since then it has travelled a long way from a theory into an analytical tool and from the feminist literature to a variety of academic disciplines including social behavioural and health sciences 51 crenshaw contended that the singleaxis analysis on the basis of sex alone or race alone obscures the multiple dimensions of discrimination and violence experienced by the women of colour 49 52 an argument that serves as the core spirit of intersectionality theory although intersectionality has become a buzzword there is still a lack of consensus on what might be regarded as an intersectional approach to research a working definition recently proposed by elsequest and hyde 53 identified three essential elements of intersectionality individuals are characterised by multiple socially constructed categories including gender race social class immigration and these social categories are intertwined membership in any of the social categories is linked to power and inequality social categories are characteristics of the individuals as well as of the social contexts and as such their meanings are fluid and dynamic in order for any study to qualify as on may 7 2024 by guest protected by copyright bmj glob health first published as 101136bmjgh2019001938 on 2 march 2020 downloaded from bmj global health intersectional it is not enough to merely test interactions between different social strata 54 an intersectionalitymotivated study must pay attention to the structures of power privilege and oppression that shape the social experiences of people with different intersectional identities nowadays there has been a growing interest in the application of the intersectionality scholarship to the investigation of health inequalities whereas intersectionality as a framework has gained prominence in qualitative research suitable methodological strategies in quantitative research have only recently begun to emerge keeping pace with the theoretical advance 54 55 56 57 58 59 60 two methodological approaches can be distinguished in the intersectional quantitative literature the fixed effects approach and the multilevel analysis of individual heterogeneity and discriminatory accuracy approach 61 the conventional fixed effects model examines intersections either by accommodating the additive main effects of the social strata as well as all possible interaction terms 59 or by using crossclassified categories representing intersections between social groups 62 63 this analytical strategy is particularly useful when the dimensions of identity are relatively few however as more categories of identity position and social process are added to the analysis the number of parameters grows geometrically since the model has to allow all possible combinations of first second and higher order interaction terms this inevitably gives rise to a number of methodological concerns regarding model fit and parsimony reliability of estimates due to low statistical power in some intersectional strata and the issue of interpretability of the parameters 59 60 most of the limitations associated with the fixed effects approach are effectively handled by a multilevel intersectional approach termed as maihda which is a recent methodological innovation 59 60 64 and is hailed as the gold standard for investigating health inequalities at the intersection of multiple social dimensions 61 multilevel modelling is typically used to account for clustering or similarity between individuals a phenomenon induced by a shared context the intersectional maihda is a twolevel hierarchical model in which the individuals are nested within the macro societal context represented by a matrix of intersectional social strata which is defined by the unique combinations of all social identities or variables considered in the analysis while the characteristics such as gender race class and migration status are modelled as individuallevel variables in the fixed effects or the classical multilevel approach the same variables are explicitly modelled as the properties of the social context in the maihda approach the practical advantages of the maihda model over the conventional model are that the former adjusts for sample sizes by default and assesses interaction effects without having to fit any interaction terms through an estimation of stratalevel residuals 59 60 an intersectional approach to migrant health does not require an entirely new set of methods the existing theoretical and methodological tools underpinning the intersectionality framework can be extremely useful in the immigrant health context particularly to delve deeply into the paradoxical healthy immigrant effect frequently reported in the literature which might be due in part to immigrant heterogeneity that is often unaccounted for it is evident that the intersectionality framework calls for a thorough and rigorous investigation of the complex interactions between migration status marginalisation processes and other forms of discrimination in the production of health inequalities 35 the plausibility that the effects of migration on health conditions are altered by the effects of other social identities and positions 65 requires an increased attention to the ways in which different axes of social stratification for example migration status gender raceethnicity socioeconomic position sexual orientation disability and religion intersect with each other the demand of a broad intersectional approach to migration is to attend to the hierarchy of social determinants prevailing across the whole migratory trajectory that is the determinants originating from the countries of origin transit and destination 66 conclusions while the decision of migration is influenced by a complex interlocking of a wide variety of economic social political and environmental stressors there has been a growing awareness to put these factors into the broader context of globalisation and climate change within which international migration now occurs globalisation promotes growth and development but at the cost of widening inequalities and environmental deterioration which in turn stimulate and sometimes force people to move in search of better life chances and a better living environment therefore the contemporary upsurge in international migration is a visible consequence of globalisation the interplay between globalisation and environment in combination with the local sociopolitical contexts has reportedly accelerated this trend in recent times with humaninduced climate change emerging as a dominant factor that is likely to drive population movements in the foreseeable future if migration would not impact on health and health inequalities the growing phenomenon of migration would just be an issue of academic interest without being a genuine cause for public health concern however migration does affect health through processes that systematically exacerbate vulnerabilities to health hazards thereby challenging the global health equity movement the migrants can actually be a healthier group compared to both the population they join and the population they leave behind with the exception of the forced migrants however the healthy profile of the migrants tends to be offset over time as they settle in the new society bmj global health in immigrant health research the hegemonic cultural perspective explains the immigrant health transition as having to do with their acculturating towards the lifestyles and healthrisk behaviours of the mainstream population the acculturation framework however ignores the structural factors affecting the social and economic integration of the migrants who are discriminated and marginalised through the process of othering the structural perspective came up with the promise to explore the structural factors but a full examination of such factors is currently hampered due to an overwhelming focus on access to healthcare and inadequate attention to institutional and social contexts in order to do justice to the phenomenon of increasing heterogeneity in the immigrant populations and the complexity of the link between migration and health the structural paradigm must turn the spotlight on the wider sphere of sdh in which migration needs to be positioned as a social determinant in its own right the intersectionality framework has the potential to further enrich immigrant health research through greater attention to the upstream causal processes and going beyond the master category of migration status to multilevel social categories that intersect to produce health inequalities

the rapid growth of international migrants in a globalised context and the heterogeneity of immigrant populations pose a big challenge to public health policy and research ► the empirical literature on immigrant health broadly showcase a healthy immigrant effect with concurrent evidence of downward health trajectory over time ► from the acculturation perspective the assimilation of unhealthy behaviours is to blame for immigrants downward health trajectory while the traditional structural framework attributes it to restricted access to healthcare ► immigration itself is determined by economic social political and environmental factors and hence its association with health cannot be clearly understood independent of the upstream causal forces ► the modern intersectionality framework has the potential to advance immigrant health research through a simultaneous focus on multiple dimensions of systematic vulnerabilities and discrimination

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introduction men who have sex with men bear a disproportionate burden of the hiv epidemic 1 in 2019 the joint united nations programme on hiv and aids reported that gay men and other msm accounted for 17 of all new hiv infections globally 2 and that their risk of hiv acquisition was 22 times higher than for heterosexual men similarly in east and southern africa msm were reported to contribute to 17 of new hiv infections 2 data from studies conducted between 2011 and 2014 among msm in malawi found hiv prevalence ranging from 182 to 214 34 this is more than 3 times the national average of 64 among men ages 15 to 49 years in the general population 5 in september 2015 the world health organization recommended oral preexposure prophylaxis as part of a combination hiv prevention approach 6 for people at substantial risk of hiv infection prep is the use of antiretroviral medication to prevent hivnegative individuals from acquiring hiv prep complements condom and lubricant use behavioral counseling treatment for sexually transmitted infections hiv testing and counseling voluntary male medical circumcision and antiretroviral therapy for partners living with hiv 7 8 9 a proportion of msm do not use condoms consistently for various reasons therefore using prep during periods of higher risk of hiv responds to this reality and strengthens comprehensive hiv prevention 10 despite the evidence of its effectiveness in preventing hiv access to prep has been limited in many countries in malawi prep was included in the malawi guidelines for clinical management of hiv in children and adults 2016 and national hiv prevention strategy 20152020 however at the time of this assessment prep was not yet readily available in the country this study was conducted ahead of the introduction of prep services in malawi to inform national scaleup of prep services especially for msm this assessment was conducted to support the design of the prep program in malawi numerous individual familial institutional and structural factors affect msms access to health care in malawi these include stigma from community members due to cultural beliefs 3 hesitancy of msm to reveal their sexual practices when accessing health care 4 which limits their ability to access appropriate services information education and counseling inadequate capacity of service providers to provide msmfriendly health services 1 2 3 4 and unfavorable social and legal environments created by the malawi penal code that criminalizes samesex relationships and encourages discrimination against msm 11 while msm have a high turnover of sexual partners low condom use and multiple concurrent partnerships they have reported low levels of individual risk perception 1213 however it is important to note that these studies were conducted several years ago and there is a need to conduct similar studies to obtain updated data on these risk factors this discrepancy between actual and perceived risk requires programs to innovate and provide a wide choice of services to msm to reduce the incidence of hiv among them 1 although the legal environment for msm transgender people and other sexual minorities remains constrained in malawi significant progress has been made in the provision of health services for instance the current national clinical guidelines for the management of sexually transmitted infections 14 and the malawi national hiv prevention strategy 20152020 15 have incorporated msmspecific interventions civil society organizations legal and advocacy partners and national and international nongovernmental organizations such as fhi360s linkages across the continuum of hiv services for key populations affected by hiv project are also providing a mix of human rights legal and hiv prevention services linkages was launched in june 2014 as the us presidents emergency plan for aids relief us agency for international development s largest global hiv project dedicated to providing holistic hiv prevention care and treatment programming for key populations in malawi through community outreach services and dropin centers the project has been providing prevention care and treatment services to key populations including msm and transgender individuals the primary aim of this study was to assess msms awareness of prep their willingness to use it and barriers they face to prep use in order to guide the design and implementation of a prep program in malawi specifically the study aimed to determine awareness and attitudes about prep factors that will likely facilitate prep uptake and adherence and potential barriers to prep uptake and adherence methods study design and population a qualitative study consisting of indepth interviews and focus group discussions was conducted to ascertain msm knowledge of and perceptions about prep uptake and adherence in lilongwe and blantyre cities and the two rural districts of mangochi and mzimba north these districts were targeted as the project leveraged on the infrastructure of the linkages project study participants were identified in october 2018 from msm accessing hiv services from peer educators at various sites including dics supported by the linkages project as well through other projects run by the local civil society organization center for development of people prior to the study msm were engaged through cedep to provide input to the design and implementation of the study some of the input was on the questionnaire and language who to include as data collectors and where to conduct the idis and fgds among others subsequently data collectors were picked from the group of msm who participated in the consultation process the linkagessupported dics are key populationfriendly service delivery points where msm access condoms lubricants hiv testing and counseling services for genderbased violence and recreational activities men were eligible to participate in the study if they were aged 18 years or older accessed services from linkagessupported dics or cedep projects selfidentified as msm or were identified as such by peer educators and tested negative for hiv within the past 3 months sampling study participants for fgds were purposively recruited from men who accessed services at dics to ensure representation from all sites and different age groups lists of eligible study participants were drawn both from linkages dic records and records of other cedep projects and were classified by geographical location social networks and age group participants were randomly selected within each subgroup clinical staff at the dics were involved in the identification while ensuring that the participants met the eligibility criteria for the study a total of 8 fgds with 12 participants per group were conducted making a total of 96 msm participating in the fgds two fgds were conducted per district including one for younger msm ages 18 to 34 years and another for older msm ages 35 years and older a total of 13 idis were conducted comprising 3 people from each of the 4 districts and one man who has sex with other men who was involved in advocacy the idi participants were purposively selected from linkages projects and other social projects to include msm who are highly hidden from society as well as the msm community because of their social position the 3 participants from each district had at least one of the following characteristics married individuals educated at a tertiary level or working and older than 35 years data collection data were collected in october 2018 following study approval data were collected by trained study assistants using semistructured interview guides the study assistants were fluent in both english and chichewa a local language and they conducted idis and facilitated fgds in the language of each participants choice data collected from participants included information about their knowledge perceptions and concerns about prep factors that would potentially motivate them to use it barriers to prep use and service delivery preferences related to infrastructure knowledge needs and providers fgds were done with 6 to 12 participants per group and conducted at dics each fgd lasted for approximately 70 minutes and 6 of the 8 fgds were audiorecorded as participants of 2 fgds declined permission for the fgds to be recorded idis were conducted at a place convenient for the participant on average the interviews lasted 50 minutes and 8 out of 13 interviews were audiorecorded as 5 people declined to be audiorecorded idis and fgds used the same questions because the data collected in the idis supported the opinions collected in the fgds from individuals that are highly hidden and could not participate in fgds the 8 idis and 6 fgds that were audiorecorded were transcribed into chichewa or english by an independent transcriber and all interviews conducted in chichewa were then translated to english transcripts were proofread and checked for accuracy by listening to the recordings multiple times to ensure that the translation conveyed the participants answers and descriptions the aim was to produce the best possible translation and preserve the content and meaning of the original text for the 5 idis and 2 fgds that were not audiorecorded study research assistants took notes including direct quotes data analysis data were analyzed using a thematic content analysis framework where deductive and inductive approaches were used to code the data the former was guided by the literature and study objectives in identifying the themes under which data were grouped inductive analysis was then conducted by listening to the audiorecording reading through the transcripts and identifying emergent themes the data analysis followed 6 stages 16 becoming familiar with the data generating initial codes searching for themes refining themes naming themes and producing the report 17 the findings presented include quotes without identifiers to protect confidentiality ethics the study protocol was reviewed by the university of malawi college of medicines research ethics committee and fhi360s protection of human subjects committee all study staff including the study assistants were trained in ethics for conducting research with human subjects with a focus on ensuring informed consent privacy and confidentiality they were also trained on data collection tools to standardize the information to be collected and the process of data collection the data collectors were identified from the cohort of peer educators under the linkages project who are part of the msm community potential participants were informed that participation in the fgd and idi was voluntary and that refusal will not affect continued access to services written informed consent was obtained from everyone who agreed to participate participants were not compensated for participating in the study but were reimbursed for the cost of travel from their home to the study site no personal identifying information was collected during the fgd and idi study participants were assigned idsunique identifiers and no names were used idis and fgds were conducted in places that assured privacy where conversation between interviewer and interviewees and fgd facilitators and participants could not be heard by a third party results sociodemographic characteristics table 1 below summarizes the characteristics of the study participants most of the study participants were aged 35 to 40 years and the least were aged 30 to 34 years there was a uniform number of participants from the 4 participating districts awareness and attitudes regarding prep of the 96 fgd participants 40 indicated that they heard about prep before the study while 20 indicated that they heard about the drug during the survey of the idi participants 69 had heard about prep prior the study and 4 learned about it during the study i hear it a drug you take before having sex to protect yourself from catching hiv fgd participant it is a drug for hiv prevention which you take before you have sex with you partner idi participant when asked what they knew about prep 35 of the fgd participants and 67 of the idi participants said they did not know much of the fgd participants 45 who heard about prep confused prep with postexposure prophylaxis awareness was better among younger msm participants than older msm participants as they were able to describe prep as prevention before acquiring hiv i have heard about prep of which i cant describe well i heard that these are drugs to be provided to hivnegative people to protect them from hiv idi participant you use it to kill the virus within 72 hours of sleeping with someone without a condom fgd participant when asked about the main source of their information on prep the majority reported friends while others reported civil society organizations and social media family was not mentioned as one of the sources of information there were some mixed ideas about the awareness and importance of using condoms while taking prep i heard about it this other day when i was drinking at a bottle store i heard that when you do not have hiv you can take these drugs to protect yourself from hiv idi participant participants from both idis and fgds acknowledged the importance of using condoms when one is on prep to have double protection for hiv and prevent sexually transmitted infections however others pointed out that using condoms combined with prep defeats the purpose of using prep for hiv prevention as condoms similarly protect against hiv and other stis why should we use two things i wish we could be choosing between the two fgd participant some participants were male sex workers and reported that condom use with clients was sometimes challenging due to client preferences one participant described the appeal of prep in cases where he did not know clients hiv status i prefer having sex with a partner without using a condom sometimes attitude despite the limited awareness of prep there was overall a positive attitude toward prep study participants from both idis and fgds noted that since prep will reduce their chances of being infected with hiv the intervention was welcome within the msm community of the fgd study participants 67 also indicated that they would not wait for a long time or for someone they knew to use prep before using it themselves and they said they would use it right away some asked for the intervention to come to malawi soon from the idis 38 indicated that they would not wait to take prep but take it immediately as it is rolled out a total of 62 of fgd study participants indicated that they have multiple sexual partners and stated that they were more willing to use prep as an additional hiv prevention because sometimes they indulged in unprotected sexual intercourse with their partners every time i am worried about getting infected with hiv i want to have a long life this initiative will make me healthy idi participant let the drugs come we are waiting fgd participant why would we wait for a year were you trying us fgd participant once the drug is in we will use immediately we cant wait because the drug has already been tried in other countries idi participants benefits from prep all 13 idi participants indicated that if prep were available for them to use they would want to use it to benefit from the protection from hiv they mentioned preventing acquisition of hiv enjoying a long life and avoiding longterm art if they otherwise get infected as benefits they would get from using prep another benefit was that prep would be able to prevent hiv transmission to sexual partners including ones wife likewise 61 of fgd participants both young and old indicated that hiv prevention will be their primary motivation i dont know what i can do if i test hiv positive it means i have to be on antiretrovirals daily with prep maybe i would not be taking art drugs daily idi participant if i protect myself from hiv i will not have to take art for the rest of my life fgd participant formulation and dosing preferences study participants were asked which of the different frequencies of dosing they were comfortable with and in what formulation study participants were concerned about the dosing frequency and reported that they would be more likely to use prep if the dosage is not daily if we will be using daily tablets it means we will have to go to the facility to collect medications so often we do not have that kind of cash to be traveling all the time idi participant weekly is good because taking drugs brings bad taste in the mouth so taking the drug daily for a long time is not good fgd participant preferences for oral or injectable prep were mixed some indicated that they would prefer an injectable form while others wanted pills because they feared injections however some who were married indicated that they would like prep use to be disguised so that their spouses or parents would not suspect anything specifically some participants expressed that they would prefer small pills which would be less noticeable and easier to swallow i am married also to a woman she may suspect something if i am using pills every day at home idi participant once a month injection because a daily pill is too difficult to be taken and for it to be attractive it must not have more side effects idi participant msm involvement for prep demand creation and distribution participants also indicated the need to involve members of the msm community to promote awareness of the product as well as distribution of the drug they pointed out the need to build the capacity of msm representatives to share information about prep within the msm community choose msm representatives from the msm community to be like peer educators idi and fgd participants fgd participants spelled out where it is provided and who provides it study participants were asked about their health services preferences that would contribute to prep uptake and adherence dics were the most preferred service delivery point followed xsl • fo renderx by outreach services these settings were most often reported as venues where prep could be provided and accessed without concerns about stigma and discrimination many participants from fgds said they would prefer prep to be available in dics and outreach sites where there was minimal to no stigma and discrimination if you want msm to take prep then make sure that you provide services in places where we are already comfortable like dropin centers fgd participant they also proposed changes such as improved attitudes for service providers reduced waiting time and provision of clear information about prep participants felt it was important for facilities to offer the following to accompany prep services condoms and lubricants hiv testing and counseling and education on prep participants also said they would be more likely to adhere to prep if it was provided by nonjudgmental msmfriendly service providers use the friendly providers who do not take their personal beliefs to stop us from being msm those who understand that we are also human beings fgd participant two participants in idis reported a mission hospital in northern malawi as especially wellplaced to provide care for the msm community and private pharmacies were reported as potential sites by one person in an idi potential barriers for msm to prep uptake and adherence despite the positive attitude and their willingness to take prep the participants had several concerns that would stop them from taking prep which need to be considered during implementation of the services the potential side effects of prep were the most commonly mentioned concern in both idis and fgds when asked about the factors that will prevent them from accessing prep 54 of idi participants and 23 of participants from fgds mentioned side effects they are medicines just like any other medicines and inevitably there will be side effects what are these side effects … there could be smell or bad taste that one may have to deal with idi participant medicines are medicines perhaps one may vomit after taking the medicines that is why i think injections are better i do not like the taste of medicines idi participant i have some fears for example what are the side effects of prep being a drug fgd participant the costs fear of being identified as an msm insufficient information dosage and stockouts were identified in the idis as potential factors that can limit uptake of prep issues related to cost included transport costs to the point of care that could make it expensive to access prep through private community pharmacies a total of 77 of idi participants indicated that it is important to use msm peers as prep distributors use maleonly facilities and target all men and not just msm participants from idis also recommended the system should ensure that stock is consistently available the private pharmacies can be a good source of prep… but nothing from these pharmacies is provided for free we may not afford the cost of prep idi participant in public health facilities prep should be provided to all men and not just msm for contraceptives they give contraceptives to all women and not just female sex workers in that case there is no stigmatization idi participant if i go to facility and am sent back because drugs are out of stock i will not go again because i am not sick idi participant you should package the drug in a way that people should not realize that it is a drug otherwise like for me i cant take pills as it is difficult for me to keep them in the house because my wife can wonder and discover that i am an msm idi participant the good thing that i see is best to take the pill once a month because its not easy to take drugs daily as people can be forgetful and if you take once a month life will not be tough because when you take once a month you will take a long time before thinking of taking again which leaves you free idi participant if i dont know how the drug works its side effects and all other relevant information to help me make a decision i wouldnt bother to take it because it is drug i cant be sure whether it will help me or harm me idi participant common potential barriers that we identified among the fgds included stigmatization of msm by health care workers and community perception of persons on prep over 63 of fgd participants reported experiencing stigma from health providers when they accessed sexual and reproductive health services which could be similar when accessing prep services they observed that when they want to access services in public health facilities they are sometimes labeled by the providers as individuals who like sex too much three participants from the fgds pointed out that it defeats the purpose of using prep if it cannot offer dual protection for sti and hiv like condoms if we go to get lubricants and condoms the health providers think that you like sex too much fgd participant although some of the participants did not seem to care what the community would think 22 of fgds participants reported concerns about how the drug is being advertised if the drug is for msm and fsws only and people know it they will know that once you take it you are an msm fgd participant why should we use two things i wish we could be choosing between the two fgd participant mpunga et al jmir public health and surveillance xsl • fo renderx discussion principal findings this study demonstrated that the majority of msm in malawi knew about the existence of prep and were enthusiastic about being able to access it however a significant number did not have many details about prep and only learned of it during the study the overall level of understanding of prep seemed to be very limited formulation frequency of dosing place of distribution and side effects were identified as key factors that can affect the uptake and continued use of prep participants of both the fgds and idis indicated that msm should be involved in the design of any education program promoting the use of prep a total of 42 of persons from the fgds and 69 of participants of the idis indicated they had previously heard of prep common sources of information on prep included peers and the csos where they accessed services participants reported not having heard of prep from health care providers in public health facilities this could be because prep was not yet available in public health services in malawi in addition msm normally access sexual and reproductive health services from msmfriendly dics owned by csos whereas they attend public health facilities for services not related to sexual and reproductive health services a total of 35 of fgd participants and 46 of idi participants reported they had a limited knowledge of prep study participants were not aware that the whoapproved prep regimen was oral dosing and they questioned how or whether prep would work after unprotected sex with an hivinfected partner this finding suggests the need for adequate information for the msm to understand the benefits of the drug and enhance uptake the msm in this study demonstrated a positive attitude toward prep from both idis and fgds despite the limited awareness and were enthusiastic about having another option for hiv prevention a total of 67 of fgd participants indicated that they would not wait to take the drug if it becomes available in malawi one fgd participant stated the following let the drugs come we are waiting fgd participant the study identified factors that would enhance willingness for msm to take prep all participants from idis and 58 of the fgd participants expressed that the benefits of prep will motivate them to take the drug one idi participant stated the following i dont know what i can do if i test hiv positive it means i have to be on antiretrovirals daily with prep maybe i would not be taking art drugs daily idi participant a quantitative study from the united states identified that not believing that it helps was one of the barriers that hinder msm from being willing to take the drug 18 therefore this finding emphasizes the need for promoting awareness of the benefits of prep other factors that promote willingness to take the drug include formulation and dosing of the medication with mixed expression with some liking the pills and others injection in terms of dose some did not care about daily dose while others preferred weekly dose the responses could have been mixed because the participants were asked leading question between oral and injectable and among daily weekly and monthly doses which could be different to reality where there are not many options however proper counseling will be needed to help msm make the right choices and develop positive attitudes toward available formulation and dosage msm involvement in demand creation for the drug was another motivating factor as it will enhance peer motivation where the drug is provided and who provides it was another factor to enhance willingness considering that the medication is taken by people who are not sick they may be easily put off if the environment of providing the service is not favorable this is one of the key areas to address as many msm face stigma and discrimination within the health care system and from the community 1 2 3 4 participants also expressed barriers to potential use of prep with the highest concern being about potential side effects expressed in both idis and fgds this may not appear to be a major issue for the program since a review of the combination antiretroviral prep regimen tdfemtricitabine taken as a single pill once daily showed that only 2 out of 15678 participants discontinued therapy because of side effects 19 however it will be important to educate msm about the potential side effects and how to manage them and to address this perception regarding the side effects of the drug participants also discussed other barriers to potential use of prep lack of relevant information on prep the need to take prep daily potential stigma from public health facility providers stigma from the greater community if prep is thought to be used by msm only forgetfulness and the costs required to access the drug study participants were also concerned that even if they themselves used prep their partners may be exposed through their other partners therefore there is need for universal partner education about prep however these concerns are not unique to msm in malawi as these similar issues were noted in a review of 18 randomized controlled trials on prep stigma an unacceptable dosing regimen side effects low risk perception low decisionmaking power and the logistics of daily life 20 in another preprelated study from kenya there were concerns around the competency of service providers to understand the multifaceted issues that key populations face 21 this relates to the finding in our study that it is important to understand the needs of msm before implementing prep services to promote uptake of services these concerns may result in nondaily use of prep 22 thereby providing lessthanoptimal protection prep programs will need to develop and implement strong information and education interventions to ensure that high levels of knowledge among prep users are achieved the new prep program in malawi needs to use a multifaceted approach to educating msm about prep and ensuring access to prep this may include dissemination of information through msmfriendly service providers who understand their needs use of msm peers as educators and distributors of prep and use of dics to deliver services as well as maleonly facilities such as barber shops for information sharingwhen using public facilities they should target all men and not just msm xsl • fo renderx there will need to be various modes of delivering the messages such as face to face interaction printed materials like leaflets and online platforms among others while we expected that msm would mention the msmfriendly cso where some of the participants were recruited as a preferred setting to receive prep without stigma and discrimination outreach settings were also reported as alternatives especially for the highly hidden populations who do not go to dics nevertheless distance to the dedicated sites was identified as a bottleneck suggesting that a combination of dics and outreach facilities may be ideal hidden participants who do not go to dics were most likely to mention public and private static health services including community pharmacies as settings where prep could be offered by msmfriendly staff however it is important to note that a mission hospital in one of the districts was mentioned as a preferred site this observation is somewhat counterintuitive because of the common narrative that religious facilities exhibit homophobic tendencies this serves as a reminder that while it is possible to broadly categorize potential service providers as supportive or not supportive individual preferences may also come into play our study pointed out the need to minimize stigma and its effects in the environment where prep will be provided as a way of ensuring accessibility the stigma is usually from other members of the community and msm themselves prep services will therefore need to be offered in settings that are stigmafree to accommodate this initiative community readiness is often defined as the various attributes of a communitys context that constitute a prerequisite to the implementation of effective change thus the affected communitys knowledge and attitudes and its capacity to implement change strategies before an intervention is implemented should be reviewed 2223 it is important to take into consideration the readiness of community members other than msm to accommodate the provision of prep services to avoid the fear of stigma underscored in this assessment limitations since the study was qualitative with nonprobability sampling it was not designed to quantify the proportion of msm in the study area who find prep acceptable the findings may not be generalizable beyond the study setting and study groups because the study largely included msm who accessed health services through the linkages project or other projects within the same coverage and did not include msm who are not obvious and regular health and social service users however idis included msm who are more hidden and access health and other social services through other projects within cedep data were collected through selfreport and so may be influenced by social desirability bias however the risk of this bias was mitigated by the research assistants not being health professionals and by the fact that they too were members of the msm community therefore there was less likely to be a power differential between the study participants and the study assistants while a few key quotes may have been missed from the 2 fgds and 5 idis that were not recorded we do not believe that this significantly affected the overall conclusion from the study conclusion the study provided insights on areas to pay attention to when designing a prep program for msm in resourceconstrained settings where msm are criminalized like malawi it is critical to engage the msm community to develop msmappropriate and relevant educational and informational materials on prep to address most of the concerns raised in this study and possibly promote both uptake and adherence prep counseling should include but not be limited to information on side effects and how to manage them and the expected duration of side effects awarenessraising activities should involve msm as champions and provide clear information on the importance and value of taking prep in relation to the perceived risk of contracting hiv to promote adherence regardless of prep formulation making communitybased distribution of prep more prominent could avoid potential accessibility barriers but it is critical to also consider how to target prep within the general population to reduce stigma and the perception that prep is only for msm and other key populations furthermore implementers should consider development of innovative publicprivate partnerships and explore how msmfriendly health workers in the public and private health system may be mobilized and trained for the provision of prep in addition to usual safe spaces such as dics other suggested factors necessary to improve access through health facilities should also be addressed authors contributions em and np designed the study em coordinated the study and collected data db and ca supervised the study em np and db analyzed the data em np ca and db developed the first draft of the manuscript all authors contributed to and approved the final manuscript conflicts of interest none declared ©elizabeth mpunga navindra persaud christopher akolo dorica boyee gift kamanga gift trapence david chilongozi melchiade ruberintwari louis masankha banda originally published in jmir public health and surveillance 27102021 this is an openaccess article distributed under the terms of the creative commons attribution license which permits unrestricted use distribution and reproduction in any medium provided the original work first published in jmir public health and surveillance is properly cited the complete bibliographic information a link to the original publication on as well as this copyright and license information must be included abbreviations

background men who have sex with men msm are a key group for hiv interventions in malawi considering their high hiv prevalence 175 compared to 84 among men in the general population the use of oral preexposure prophylaxis prep presents a new opportunity for msm to be protected we present the findings from a qualitative assessment designed to assess awareness of and willingness and barriers to using prep among msm in malawithe 3 main objectives of this assessment were to determine 1 awareness of prep 2 factors that influence willingness to use prep and 3 potential barriers to prep use and adherence among msm in order to guide the design and implementation of a prep program in malawi methods ahead of the introduction of prep in malawi a qualitative study using indepth interviews idis and focus group discussions fgds was conducted in october 2018 in blantyre lilongwe and rural districts of mzimba north and mangochi with support of members of the population study participants were purposively recruited from 4 msmfriendly dropin centers where msm receive a range of health services to ensure representativeness across sites and age participants were asked what they had heard about prep their willingness to use prep their barriers to prep use and their preferences for service delivery the data were analyzed using a thematic content analysis framework that was predetermined in line with objectives results a total of 109 msm were interviewed13 through idis and 96 through fgds most participants were aware of prep as a new hiv intervention but had limited knowledge related to its use however the majority were willing to use it and were looking forward to having access to it idi participants indicated that they will be more willing to take prep if the dosing frequency were appropriate and msm were involved in information giving and distribution of the drug fgd participants emphasized that places of distribution and characteristics of the service provider are the key factors that will affect use knowing the benefits of prep emerged as a key theme in both the idis and fgds participants highlighted barriers that would hinder them from taking prep such as side effects which were cited in idis and fgds key factors from fgds include cost fear of being outed drug stockouts fear of being known as msms by wives and lack of relevant information fgds cited stigma from health care workers forgetfulness and community associated factors

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introduction a considerable body of evidence has identified psychosocial risks as features of work organization that may harm workers health and wellbeing 1 research is prolific on the relationship between psychosocial risks and cardiovascular and mental illnesses two of the most challenging illnesses in occupational health and safety and public health in general especially in western societies 2 3 4 using the demandcontrolsocial support 56 and effortreward imbalance models 7 exposure to these risks at the workplace has been related to anxiety and depression 89 and myocardial infarction or stroke 1011 among many other health disorders furthermore longitudinal studies and metaanalyses with large databases have been able to rule out chance associations 12 additionally scientific literature has shown major occupational class disparities on psychosocial exposures connected with other socioeconomic and sociodemographic factors 13 in a segmented labor market derived from the unequal implementation of labormanagement practices 14 15 16 moreover recent studies on trends in psychosocial working conditions in the european union and united states have observed persistent inequalities by occupational groups in the european working conditions survey data from 1995 to 2015 salaried and wageearning employees in lowerskilled occupations not only had higher levels of job strain and effortreward imbalance on average but they also experienced a steeper increase in job strain than employees in higherskilled occupations in the original 15 european union countries during that period the persistent low job control for lowskilled manual jobs during the 20year period of the survey reflected a decrease in skill discretion and persistent low decision authority 17 similarly job control remained at higher levels for the management and professional groups and at low levels for service and bluecollar jobs consistent with the findings from the 20022014 niosh quality of work surveys 18 for the us population this public health literature also points to organizational interventions at the workplace to minimize psychosocial job exposures as a step to promote workers health 1920 along this line the research to date suggests that various aspects of labormanagement practices such as working time arrangements working methods job design employment relationship and salary structures are modifiable work features at the origin of workplace psychosocial exposures 21 22 23 24 25 however it still remains a vast area to explore 26 more than 40 years of public health research supports the harmfulness of taylorism toward physical and mental health 21 due to division fragmentation and standardization of work which in turn are associated with low control high work pace lack of social support and low recognition at work in contrast scholars have debated the relationship between direct participation practices and working conditions with few studies on psychosocial risks direct participation practices have been defined in the literature as labormanagement practices that involve some kind of decentralization in decisionmaking from management toward workers either individually or in groups entailing different degrees of discretion or powers and different topics or scope which may determine their relationship with working conditions 27 28 29 however relevant comparative evidence on different forms of direct participation and working conditions is scarce with debates being more conceptual than empirical 30 according to degrees of discretion that is the extent to which managers let workers be involved in decisions direct participation could be categorized as delegation when management grants decisionmaking capacity to workers and as consultation when management encourages workers to make their opinions known but reserves the capacity to accept or reject them 31 delegative direct participation practices underpin labormanagement models such as the humanization and democratization of work sociotechnical systems and high involvement or learning organizations mostly associated with a healthier working environment team or individual autonomy to make decisions in enlarged and enriched jobs is considered one of the key factors for exerting influence in and over work in giving better chances for using abilities learning and developing on the job in increasing the opportunities for cooperation and for being recognized as a professional 32 33 34 some research critical of highperformance management warns of its negative effects mostly referring to individual delegation among nonmanual jobs despite its rhetorical support for workers personal and developmental needs 3536 inside the selfmanagement paradigm while workers may enjoy considerable discretion regarding how they carry out their duties their workload is overburdened and their performance is under constant scrutiny their autonomy being partial and contradictory 283738 on the other hand consultative direct participation practices have been studied as part of lean production high performance and new public management and they have also been associated with excessive demands in terms of effort and commitment increased peer competitiveness and work intensification among manual and nonmanual jobs 21 39 40 41 42 43 44 nevertheless some scholars have suggested that consultative direct participation practices are crucial for achieving positive effects on working conditions when lean production is implemented 45 46 47 48 49 50 regarding direct participation scope that is the topics about which managers allow workers to decide themselves or to take part in decisions direct participation may address operational issues or tactical issues as far as strategic content participation if any is mainly reserved to workers representatives 2728 direct participation studies which considered scope typically involved delegation on operational matters and consultation on tactical issues as reflected for example in the typology used by eurofound from 2013 onwards 5152 this study focuses on direct participation practices and its results suggested that all forms are associated with better working conditions for instance gallie and zhou 51 using european level data showed lower levels of work intensity increased informal learning and higher possibilities to experience management support when consultation on tactical issues or delegation about operational issues were implemented in companies llorens et al 53 working with spanish data found no association with quantitative demands and more frequent and stronger positive associations with control social support and rewards when using delegative and consultative direct participation practices simultaneously and among manual jobs felstead et al 54 using data from the uk found these practices associated with skill utilization and with lower required effort and work exhaustion moreover dhondt et al 55 using data from denmark ireland the netherlands finland sweden and the uk showed high work intensity being associated with less delegation and not associated with consultation which in turn was positively associated with wellbeing furthermore these studies suggest that direct participation practices may reduce occupational class differences in working conditions 3051535657 therefore direct participation was mostly studied in combination with other labormanagement practices as part of one labormanagement model only some studies assessed direct participation practices and their relationships with working conditions comparing specific degrees of discretion while mixing the scope very few others linked direct participation practices to workrelated psychosocial risks distinguishing between occupational groups and even fewer have used an assessment instrument validated in the field of occupational health the potential of different degrees of discretion and scope in direct participation practices to promote a better psychosocial work environment at the company level across different occupational groups is still unclear 58 consequently the present study aims to expand the empirical evidence about the role of specific features of direct participation practices as social determinants of psychosocial exposures and health promoting practices which may differ among occupational groups measures independent adjustment and stratification variables four variables were created for direct participation two indicators were created as independent variables one on operational issues and the other on tactical issues both distinguishing between different degrees of discretion this allowed for an empirical discussion not only about the relationship between workrelated psychosocial risks and different degrees of discretion in using direct participation practices but also on the relationship with the different topics addressed by them ten other labormanagement practices variables on working hours employment relationship promotion salary and staffing were considered potential confounding factors in addition to sex and age they were chosen by a multidisciplinary panel of experts comprising sociologists economists lawyers and epidemiologists and were taken from an earlier study which used data from the spanish psychosocial risks survey carried out in 2005 to investigate the associations between these variables and the psychosocial work environment 60 occupational group was used as the stratification variable measured with the 2011 national classification of occupations at the onedigit level and then dichotomized into manual and nonmanual occupations 61 dependent variables the survey included the copsoqistas21 v3 59 the spanish adaptation of the copenhagen psychosocial questionnaire an internationally validated instrument for the assessment of workrelated psychosocial risks 62 the copsoq questionnaire allows for the operationalization of the most prominent work social support from colleagues and supervisor and recognition each one was measured on a scale comprising between two and four 5point likerttype items for the analysis the answers to the questions were added and standardized with scores ranging from 0 to 100 the scores were then dichotomized considering the 25 at most risk as poor and the rest at good for health in each psychosocial dimension t a b l e 1 statistical analysis sampling weights were calculated to account for the probability of a worker being selected according to the sampling design and to comply with the sex and occupational group distribution of the spanish salaried and wageearning employees taken from the survey of the active population for the last quarter of 2015 robust poisson regression models were fitted to estimate adjusted prevalence ratios with their respective 95 confidence intervals to establish possible associations between different direct participation practices and workrelated psychosocial risks stratifying by occupational group all analyses were conducted considering the sample design by using the svy command of the stata statistical package version 120 results direct participation practices were associated with a better psychosocial work environment after adjusting for other labormanagement practices sex and age and after stratifying the population by occupational group significant associations always positive were more frequent and stronger among manual occupations compared to nonmanual ones regarding direct participation practices characteristics in both occupational groups when consultation and delegation were used in combination the associations with psychosocial work environment were always positive more frequent and stronger when they were used separately a different picture emerged among manual occupations associations with a better psychosocial work environment were stronger and more frequent when using consultation while in nonmanual occupations they were stronger and more frequent when delegation was used among workers in manual occupations discussion when comparing the situation of workers to whom direct participation practices were applied with that of workers among whom these practices were not used our results corroborate those of previous research indicating that direct participation practices are associated with better psychosocial working conditions 30 32 33 34 45 46 47 48 49 50 51 53 54 55 56 57 the use of direct participation practices was either associated consistently with a healthier psychosocial work environment or it was null therefore according to our results direct participation practices have a potential of reducing workrelated psychosocial exposures and their uneven distribution and consequently for decreasing workrelated diseases and health inequalities 20 t a b l e 3 prevalence ratios between psychosocial work factors and direct participation practices salaried workers in nonmanual occupations regarding degrees of discretion for both manual and nonmanual occupations more frequent and intense improvements of psychosocial work environment were observed when consultation and delegation were used in combination as expected 51 when consultation and delegation were used separately consultation led to a healthier work environment among manual occupations which we had not hypothesized in contrast delegation had better results than consultation among nonmanual occupations as expected regarding topics direct participation on tactical issues had better outcomes than on operational issues among nonmanual occupations as expected however among manual occupations both operational and tactical issues had similar good results an unexpected finding 3263 so for both workers in manual and nonmanual occupations higher discretionary degrees of participation were important for the psychosocial work environment meanwhile topics were only important among nonmanual occupations demands no relationship was observed between direct participation practices and work pace neither among workers in manual occupations nor among those in nonmanual occupations though consistent with previous studies 535564 this result was unexpected since a substantial part of the literature links direct participation to work intensification 3840 65 66 67 68 however in most cases direct participation practices have been studied in the context of lean or highperformance management models and therefore in conjunction with other management practices that are associated with work intensification such as performancerelated payment 69 justintime waste and nonadded value activities reduction or standardized work 45 70 71 72 and understaffing 65 which could compromise positive results of direct participation practices 4873 moreover unlike previous research on direct participation our results were adjusted for other known causes of work intensification such as poor planning 37 time availability demands 74 or staffing level constraints 7576 such controls may account for the differences between our results and the negative ones observed in previous studies in other words our research adds evidence to the literature suggesting that the main causes of the work intensification may be wider resource pressures and other related labormanagement practices that contextualize direct participation implementation rather than the direct participation practices themselves 3353 75 76 77 78 control among workers in manual occupations the implementation of direct participation practices regardless of the degree of discretion or topic was more frequently and strongly associated with possibilities of development and influence meaning greater possibilities for applying and developing skills and knowledge and to a lesser extent for influencing decisionmaking processes triggering the human capacity of thinking creatively arguably tasks in manual jobs are mainly designed to be simple and standardized with very low possibilities to bring into play skills and knowledge consequently for workers in these occupations being consulted or deciding about operational or tactical issues could change this situation enabling their knowledge and skills to be applied and challenged 4554 and in doing so enhancing their dignity at work 79 moreover delegation and consultation may facilitate informal learning 51 delegation through developing own job tasks 33 and consultation through knowledge sharing 56 allowing learning from coworkers and from linemanagement 80 thus acquiring new skills and knowledge 6681 when used separately consultation had stronger associations with control than delegation among manual occupations in other words consultation emerged as being more professionally stimulating than delegation which theoretically was an unexpected result 63 as for operational topics since the tasks involved are relatively simpler autonomy stemming from delegation can be trivial 80 therefore being consulted on how to improve the way tasks are performed might be more stimulating than delegation on how to do them moreover consultation could result in more professional development since it may occur in group structures more often than delegation 82 group structures could make sharing experiences and reflecting with peers easier 80 additionally consultation may imply a need to make inputs by management resulting in a sort of vertical decentralization of information that otherwise workers would not know 83 all in all consultation may extend knowledge flows enabling the use and learning of skills and knowledge in a more protean and substantive way than delegation for certain occupations among nonmanual occupations more favorable results for delegation than for consultation are observed similarly better results for tactical topics than for operational ones were observed as theoretically expected for the dimensions of control and recognition delegation on tactical issues poses more challengesthat is thinking creatively acquiring new information learning new tasks having more decision latitudeand implies greater respect for workers workrelated knowledge 3234 even so the associations between direct participation practices and control dimensions were less strong and less frequent among nonmanual occupations than in manual ones despite the increasing tendency toward routinization 84 nonmanual jobs still have a richer content than many manual jobs and may therefore have less room for improvement with the implementation of direct participation practices 5256 recognition for workers in manual jobs only combined use of consultation and delegation showed relatively strong associations with recognition irrespective of the topic so only when these participatory processes mean management actively seeking and listening to proposals from rankandfile workers on operational and tactical issues plus allowing them to decide are indicators of managements recognition and respect probably their joint use shows a truer management commitment to workers as experts and management respect for manual workers workrelated knowledge 4585 44 social support among workers in manual jobs no associations were found between social support and delegation used alone meanwhile consultation either alone or in combination with delegation presented favorable associations with support thus our research suggests that support from colleagues and supervisors for doing ones work is promoted by consultation among workers in manual jobs it could be that consultation is applied more frequently in group format than delegation making it easier to help each other that may be the case since for example 2015 ewcs results 82 revealed that only 10 of the salaried and wageearning employees worked in teams with autonomy regarding coworkers social support it could be argued that consultation gives opportunities to speak up and listen to others problems 85 and to solve problematic situations making the work easier 4686 correspondingly these practices may create not only a group structure but a collective process that promotes collaboration not only during the consultation but also in everyday work this could be especially important in jobs in which the individual is the basic unit of design as it is more frequent among manual occupations the positive associations with supervisors support could be related to the need of redefinition of linemanagers tasks in consultation structures where they are asked to be facilitators and to collaborate with rankandfile workers these new tasks related to functional support may be carried out by line managers outside the consultation structures also in everyday operations 51 the stronger associations with support when consultation is used to tackle operational issues might be related to their greater connection to everyday work than tactical issues in contrast the lack of association with social support dimensions among nonmanual occupations suggests that they do not need the leverage of direct participation practices to create structures to work in a collaborative manner the 2015 ewcs results 82 showed that workers in nonmanual occupations are more likely to work in teams yet these results were unexpected since some previous research reported inverse associations between direct participation formulas and social support 3940 which again may be due to the influence of other labormanagement practices that are applied and studied in conjunction with direct participation practices which in turn were controlled in our study these practices may include performancerelated payment 69 and understaffing 87 both associated with work intensification and compromising time needed to support peers 8889 limitations and strengths the crosssectional nature of this study limits the inferences about the causal direction of the associations which must be more rigorously tested through longitudinal research or experimental designs moreover developing a qualitative part of this study using focus groups or interviews to workers in manual occupations would be pertinent to understand better how direct participation practices may lead to healthier working conditions the study lacks contextual data even at the company level however the aim of the research was not to explore the determinants of direct participation implementation or its patterns but its associations with workrelated psychosocial risks according to segmentation theory 1690 the factors relevant to working conditions are on the demand side it is the labormanagement practices that determine them at the company level and this is the reason why our controls were other labormanagement practices which could be associated with the psychosocial work environment 1321 still the role of workers representatives could be significant evidence from the field of occupational health showed where there is unionized representation of workers with collective power and a proactive approach preventive action is more frequent and has better results 91 92 93 94 95 also in relation to direct participation practices implementation 9697 however our analysis does not address representative participation which in the european union is based on workers rights recognized through legislation and collective bargaining 98 a focus on representative participation together with direct participation practices would allow a discussion about ways of challenging the distribution of power on questioning the management prerogative on strategic issues and about democracy in the workplace 99 but it would require a different analytical framework and additional data that of industrial relations from the segmentation theory perspective labormanagement practices are conditioned as well by their social institutional and economic context and in turn are key factors in shaping these contexts 14 finally due to the same limitations we cannot rule out the possibility that both a healthier psychosocial work environment and direct participation practices result from a common cause such as psychosocial safety climate 100 which is also shaped by the economic political legislative and labor relations context however a significant amount of covariates were adjusted in the models thus a number of cofounders were controlled the fact that these issues were not analyzed at the macro meso and micro levels is another limitation of this study more research is needed that includes these levels using different methods to evaluate the role they play in the association between workrelated psychosocial risks and direct participation practices 3958101102 the data used come from a representative sample of employed workers in spain while the results corroborate prior research on direct participation practices in other geographical settings with quite different socioeconomic and institutional contexts such as eu27norway and uk greece sweden the uk or new zealand 334651555664 the labormanagement practices and the workrelated psychosocial environment in spain have characteristics and idiosyncrasies of their own 51103104 as a result this study has expanded the evidence on the relationship between direct participation practices and working conditions and it gives some clues for their healthier implementation at company level particularly among workers in manual jobs conclusion remarks comparing the situation of workers to whom direct participation practices are applied with that of workers among whom these practices are not used this empirical contribution showed that direct participation practices have the potential to reduce exposure to psychosocial risks among workers especially in manual occupations achieving healthier working conditions and improving job quality according to our results direct participation practices may expand manual workers opportunities for applying their skills and knowledge and thus increasing their workrelated dignity and their learning of new abilities they provide more chances for supportive contact with coworkers and supervisors increase possibilities of attaining influence over their work and to a lesser extent increase recognition from management without increasing work intensification moreover better outcomes are to be achieved when consultation and delegation are used in combination but even when consultation is used alone and confined to immediate job issues such as operational topics this form of work organization based on allowing rankandfile workers to have a say in their daytoday activities has favorable results the best results for using direct participation practices among workers in manual jobs are found in the psychosocial risk dimensions of control and social support on the one hand low levels of control and support have been reported to contribute significantly to the development of illnesses of great importance in western countries such as coronary heart disease 1 and mortality 105 depression 8106 and death by suicide 107 on the other hand there are major and persistent inequalities in control and support between workers in manual and nonmanual occupations 1718 moreover following our evidence and as other investigators have argued 33485471 75 76 77 78 it could be hypothesized that other related labormanagement practices together with wider resource pressures that frame direct participation practices may be the cause of healthimpairing results found in some previous research rather than the direct participation practices themselves more research is needed to draw conclusions on this direct participation does not change the basic power structure 85 but it may be an effective means to reduce unhealthy working conditions and occupational inequalities at the company level 20 following findlay et al 75101 while acknowledging financial institutional and technological pressures which condition the implementation of these labormanagement practices it is for the management who holds the executive power in the workplace 939697 to decide whether to use direct participation practices to achieve a healthier psychosocial work environment and better job quality conflict of interest the authors declare no conflict of interest disclosure by ajim editor of record paul a landsbergis declares that he has no conflicts of interest in the review and publication decision regarding this article ethics approval and informed consent all research procedures were approved by the ethics committee on animal and human experimentations of the autonomous university of barcelona and by istas research ethics committee participation of salaried population was voluntary and all participants provided informed oral consent data were rigorously anonymized before analysis supporting information additional supporting information can be found online in the supporting information section at the end of this article how to cite this article llorensserrano c salasnicás s navarroginé a lluís sm delegation and consultation on operational and tactical issues any difference in their potentialities for a healthier psychosocial work environment am j ind med 202265800812 doi101002ajim23414

background despite the growing number of studies on direct participation labormanagement practices little is known about the role of their different discretionary degrees delegation or consultation and topics in their relationship with the psychosocial work environment by occupational groups methods crosssectional study on the relationship between direct participation and workrelated psychosocial risks using copsoqistas21 v3 on a representative sample of the salaried and wageearning employees in spain n 1807 prevalence ratios were calculated using adjusted poisson regression models controlling for 10 other labormanagement practices sex and age and stratified by occupational group results the use of direct participation was either associated consistently with a healthier psychosocial work environment mostly in manual occupations which presented twice as many positive associations as nonmanual occupations and of greater strength mostly in the control and social support dimensions or there were no significant associations mostly among nonmanual occupations and in relation to work pace more frequent and stronger associations were observed when consultation and delegation were used in combination if used separately consultation achieved better results among manual occupations and delegation among nonmanual occupations direct participation topics were not important for results in manual occupations whereas results were better on tactical vs operational issues in nonmanual occupations conclusions direct participation does not change power structure but it may be a useful intervention at the company level to reduce workrelated psychosocial exposures and associated diseases among workers in manual occupations and consequently for decreasing occupational exposures and health inequalities

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promote healthcare utilisation in groups and communities with low income for older adults and other vulnerable groups such as women and children the corrected texts should read this explanation is supported by previous assertions and observations by who 42 and van der wielen et al 35 that social protection schemes such as health insurance promote healthcare utilisation among groups with low income including older adults in paragraph 4 in the discussion section the original texts were older adults who did not encounter communication problems with healthcare providers had higher odds of utilising healthcare services compared to those who experienced communication providers with providers the corrected texts should read older adults who did not encounter communication problems with healthcare providers had higher odds of utilising healthcare services compared to those who experienced communication problems with providers in paragraph 1 in the conclusion section the original texts were correction system institutional and clientlevel factors associated with formal healthcare utilisation among older adults with low income under a social protection scheme in ghana williams agyemangduah 1 dennis asante 2 joseph oduro appiah 3 anthony kwame morgan 4 isaac verberk mensah 5 prince peprah 6 and anthony acquah mensah 4 we argue that specific system institutional clientlevel factors contribute to formal healthcare utilisation among older adults with low income the corrected texts should read we argue that specific system institutional and clientlevel factors contribute to formal healthcare utilisation among older adults with low income the original article 1 has been updated

following publication of the original article 1 the authors reported that three paragraphs should be updated to correct the grammatical mistakes in paragraph 2 in the discussion section the original texts were this explanation is supported by previous assertions and observations by who 42 and van der wielen et al 35 that social protection schemes such as health insurance

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introduction obesity has been a global concern despite joint efforts by nations to set goals to slow its rise in the last three decades no countries have had clear downward trends in obesity 12 in brazil overweight and obesity in the schoolage population continue to grow in all regions the prevalence of overweight among adolescents aged 15 to 17 years was 194 corresponding to 18 million people and higher among female adolescents than male adolescents regarding obesity the prevalence among female adolescents was also higher than among male adolescents 3 the prevalence of obesity in brazil is smaller in rural areas than in urban areas 4 nevertheless it is growing following overall obesity increases in recent decades 4 and studies related to lifestyle and eating habits are still limited in rural areas 5 unhealthy eating habits and low physical activity are social behaviors shared among family friends schoolmates and neighbors that is the behavioral norms of friendship groups can spread through the social network influencing or not the development of process of being transferred or withdrawn from school activities due to a medical certificate at the time of data collection were excluded from the study the research ethics committee approved the study of the federal university of rio grande do norte number all participants were informed about the research objectives and agreed to participate signing the informed consent term minors were included in the study after written informed consent of the mother or legal guardian participants did not receive any incentive or reward for participating in the study study variables the selfadministered questionnaire was based on the national health school health survey 24 adapted by the researchers containing questions about sociodemographic characteristics food consumption habits fresh fruit or fruit salad vegetables sweets fried snacks soda salty industrializedultraprocessed foods stuffed biscuits beans rice red meat white meat and milk and derivatives and the routine of how many days a week the participant had breakfast and physical activity adolescents were also interviewed and answered a questionnaire about social networking questions anthropometric measurements trained nutritionists took participants height and weight measurements in a designated room to ensure privacy following the researchers recommendation participants wore light clothing without shoes or socks weight was measured on a digital anthropometric scale with a resolution of 100 g and a capacity of 150 kg height was measured using a mobile stadiometer the body mass index was calculated as the ratio between weight and height squared in meters and classified according to criteria established by the world health organization according to sex and age 25 the zscores for each student were obtained using the growth curves proposed by the who 25 adolescents were classified according to the bmiforage cutoff points as normal weight for z scores ≥ 2 and ≤1 overweight for z scores 1 and ≤2 obese for z scores 2 25 the weight variable was dichotomized into normal weight as a reference and overweightobesity resulting from the combination of overweight and obesity social networks the research on social networks was performed through a questionnaire where the student was asked to name people in their relationship and provide information about the quality of the relationship a trained interviewer registered the responses 2627 participants were asked to name up to 23 important people who were part of the group of their relationships to measure the close ties of students subsequently the interviewees recorded the sex of each person cited age perception of the type of body of the cited person the degree of relationship with that person the relationship of influence and whether they ate in the company of that person each student interviewed corresponds to an ego and the 23 names mentioned by the interviewee correspond to the alters of their relational environment the ego and the alters are social actors in the studied network 2628 food patterns and breakfast consumption food consumption indicators were obtained from the question in the last 7 days how many days did you consume food group the student recorded the number of days heshe consumed the following food groups of the seven food groups considered fresh fruit or fruit salad vegetables sweets fried snacks soda salty industrializedultraprocessed foods and stuffed biscuits this set of variables was used to determine the food pattern by applying the principal component analysis technique this methodology allows the collected food consumption variables to be reduced to a smaller set of variables that is it selects the more expressive variables that configure food patterns preserving as much variability as possible 2930 pca and factor analysis are two techniques widely used in multivariate data analysis both are statistical methods used to reduce the dimensionality of the data factor analysis aims to identify latent relationships between a set of observed variables that is it identifies underlying or latent factors that explain most of the variance in the data 30 the food groups that contributed to the characterization of each food pattern had a factorial load variables within this value are considered to meet the minimum necessary for the interpretation of the structure and values below this level were eliminated 31 the number of components was built based on the scree plot and it was possible to identify two groups to represent the main component used in the grouping for pca component 1 which represents the first extracted food pattern represented the largest portion of the variability of the set of variables and explained 34 of the variability and component 2 the second pattern food contributed 22 totaling 57 of the explained variability thus the food patterns obtained based on the pca were grouped into healthy and unhealthy for our study we defined unhealthy food patterns when individuals consumed foods such as stuffed biscuits sweets industrialized soda and fried snacks and healthy food patterns as those who consumed fruits fruit salad and vegetables in addition cluster analysis was used using the nonhierarchical kmeans method to categorize healthy and unhealthy food patterns the question do you usually have breakfast was evaluated as a variable reflecting the eating routine the variable was recategorized into having breakfast regularly and having it irregularly physical activity and screen time physical activity practiced at school was also evaluated with the question how many days did you have physical education classes at school dichotomized into exposure to sedentary behaviors was evaluated based on the number of hours the student spent sitting during the day screen time for playing video games time using the computer talking with friends on the cell phone and the number of hours a day spent watching television also on five days of the week except for saturdays sundays and holidays both recategorized in up to 2 h a day and more than 2 h a day confounding variables confounding variables included the following sociodemographic variables sex race income and mothers education grouped into data analysis descriptive statistics were used to examine sociodemographic food consumption and physical activity data the chisquare test was used to test the association between the analyzed variables the principal component analysis method was used to identify food consumption patterns considering the weekly frequency of healthy and unhealthy food markers the pca was followed by varimax rotation the number of components was constructed based on the scree plot identifying two groups representing the main component used in the clustering these groups were classified into healthy and unhealthy dietary patterns through cluster analysis using the nonhierarchical kmeans method for each network of egos the eigenvector centrality measure was calculated this metric considers not only the connections of a given actor but also the connections of the actors that connect to it thus it measures the importance of the actor in the network with the significance of his neighbors and is associated with the actors prestige and the power of influence he exercises in the network 32 logistic models were then used to assess the association between overweight and obesity and sociodemographic variables dietary patterns and networks the association between overweight and obesity and the variables of interest was determined by logistic regression calculating odds ratios in each case with the respective 95 confidence intervals the level of statistical significance of the values was set at p ≤ 005 after selecting the variables the goodness of fit of the final model was verified using the hosmer and lemeshow test and the roc curve that is whether the model was efficient in describing the relationship between the dependent variable and the independent variables for the test the generalhoslem package of the r software was used 33 the result value of the area under the roc curve found was 07 ≤ auc ≤ 08 considered acceptable according to the parameters 34 analyses were performed with r studio software as the primary tool for statistical analysis and ucinet net draw for network analysis post hoc sample calculation was performed using the incidence percentage of overweightobesity of 193 35 with an alpha value of 005 in order to evaluate the probability type ii error we calculated the statistical power of the study was 701 power analysis was also conducted a posteriori for the chisquare test and the logistic regression considering the sample size and alpha at 005 using gpower software the achieved power was 701 assuming a large effect size at 05 for the x2 and 97 assuming an odds ratio 30 for the logistic regression results two participants were excluded from the study for presenting incomplete information and missing values were not recorded in the dependent variable as in the independent variables the data presented in table 1 show that half of respondents were aged 1617 the mean age of the studied population was 165 years and 644 were female more than half of adolescents declared to be of mixed racecolor and with an income of up to 1 minimum wage most declared having a healthy dietary pattern and a normal bmi most mothers of the adolescents interviewed had 9 to 11 years of schooling the 90 students interviewed named 2070 alters with the various types of networks family school friends friends outside school and significant others people mentioned in the family network had the strongest degree of influence followed by friends outside of school people from the family network were referred to as the ones who most shared meals in the company of the interviewees regarding the perception of body type the obese type prevailed in the description of the members of the family network and was associated with 25 of the members of the network who were friends outside of school considering the underweight type 368 belonged to the outofschool friends network 316 to the family network and 211 to the school friends network among the alters described as having a normal body members of the friend network outside of school predominated followed by those belonging to the family network and the school friends network regarding the people with whom the students had meals members of the family network predominated followed by the network of friends outside school among the alters who indicated a strong degree of influence on the students there was a large predominance of the family network followed by alters belonging to the friend network outside school all variables evaluated showed a strong association with the type of network variables the description of the members of the family network and was associated with 25 of the members of the network who were friends outside of school considering the underweight type 368 belonged to the outofschool friends network 316 to the family network and 211 to the school friends network among the alters described as having a normal body members of the friend network outside of school predominated followed by those belonging to the family network and the school friends network regarding the people with whom the students had meals members of the family network predominated followed by the network of friends outside school among the alters who indicated a strong degree of influence on the students there was a large predominance of the family network followed by alters belonging to the friend network outside school all variables evaluated showed a strong association with the type of network variables the binary logistic regression statistical technique was used to analyze the association between food patterns consumption of breakfast and physical activity with overweightobesity covariates were selected using the stepwise method that allowed us to arrive at two models table 2 registers the independent variables and the statistics generated by logistic regression for model 1 and model 2 the binary logistic regression statistical technique was used to analyze the association between food patterns consumption of breakfast and physical activity with overweightobesity covariates were selected using the stepwise method that allowed us to arrive at two models table 2 registers the independent variables and the statistics generated by logistic regression for model 1 and model 2 the hosmer and lemeshow 33 test according to the area under the roc curve showed practically an equal percentage of correct answers for both models a value that means that the two models presented good discrimination power 34 however the second model was the best as it had the lowest aic value and good auc discrimination power thus if two or more models are well adjusted and have adequate predictive capacity one should prefer the model that involves the smallest number of parameters to be estimated which explains well the behavior of the response variable 34 and the adjusted model 2 was selected as it was the most parsimonious model 36 table 2 presents the results of the multivariate analysis in which the variables of the adjusted model food patterns and breakfast showed a positive association for the dependent variable overweightobesity the odds of being overweightobese were greater among adolescents who had breakfast irregularly than those who ate breakfast regularly regarding food patterns the odds of being overweightobese were greater among adolescents who consumed unhealthy foods than adolescents who consumed healthy foods logistic regression models were used to analyze the association between the dependent variable and each of the representative independent variables table 3 registers the explanatory variables and the statistics generated by logistic regression for model 1 and model 2 note the adjusted odds ratio of the mothers education and physical education were excluded from the model in this second analysis the quality of the fit of the final model was also verified through the hosmer and lemeshow test and the roc curve 34 in addition auc values were used to compare the models the hosmer and lemeshow test according to the area under the roc curve showed practically an equal percentage of correct answers for both models a value that means that the two models presented good discrimination power 34 however model 2 was the best having the lowest aic value and good auc discrimination power the chance of being overweightobese was greater among male students than female as expected students with an unhealthy food pattern were more likely to be overweightobese than those with a healthy one in the case of the relationship between overweightobesity and the network variable eigenvector centrality adolescents who had a network with a higher degree of eigenvector centrality that is had central alters of influential intermediation with greater proximity presented a greater chance of overweightobesity in relation to adolescent students who had a network with a lower degree of eigenvector centrality this can be illustrated in the individual network of adolescent number 40 in figure 2 where prestige is indicated by the nodes size adolescents with overweightobesity obtained larger sizes in relation to other members of the network who presented normal weight influential alternates this can be illustrated in the individual network of adolescent number 40 in figure 2 where prestige is indicated by the nodes size adolescents with overweightobesity obtained larger sizes in relation to other members of the network who presented normal weight discussion this study demonstrated the association between overweightobesity food patterns and physical activity using the analysis of social networks in adolescent high school students in a rural area of northeast brazil we also found that family and friends networks potentially influence food patterns the influence level depended on the egos behaviors and the perceptions that the egos had of the alters the family represented a high degree of influence within the social networks of the interviewees at the same time some studies 3738 have already suggested that the family meal environment offers an opportunity to discuss and disseminate values and beliefs contributing to the formation of relatively homogeneous behavior patterns nuanced by culture and historical context 38 discussion this study demonstrated the association between overweightobesity food patterns and physical activity using the analysis of social networks in adolescent high school students in a rural area of northeast brazil we also found that family and friends networks potentially influence food patterns the influence level depended on the egos behaviors and the perceptions that the egos had of the alters the family represented a high degree of influence within the social networks of the interviewees at the same time some studies 3738 have already suggested that the family meal environment offers an opportunity to discuss and disseminate values and beliefs contributing to the formation of relatively homogeneous behavior patterns nuanced by culture and historical context 38 some research has shown that students networks can influence eating behaviors physical activity and obesity 21 therefore it seems essential to understand not only the composition and structure of these networks and identify the socially connected actors but also their influences on health behaviors that can help prevent obesity and lead to interventions related to this problem 3839 in the case of this study adolescents mainly gathered with their families to have their meals and the family network exerted a more significant influence on food patterns in addition adolescents revealed a greater perception of body type such as obese or overweight within the family these results align with those indicating that social ties can influence peoples behavior 4041 these ties must be strengthened when they do not disseminate risk behaviors to health and are identified as significant for adopting healthy eating habits and physical behaviors conversely ties could be reduced when they negatively influence food and life habits and disseminate risk behaviors for obesity 4243 the influence of the family and the perception of the body as obese within the family network suggest the possibility of adopting intervention strategies aimed at improving the eating behavior of several members of the network as their influences can last until adulthood in our study the eigenvector centrality indicator was significant it measures the importance of the actor in the network by the significance of its neighbors for example a student with few connections could have a high eigenvector centrality if those few connections were with important connection actors who had attributes of significant influence and prestige with other students these network interaction channels would be the conduits that are associated with the exchange of ideas and dissemination of information on obesogenic habits that are disseminated in the network structure these results are similar to those reported by other researchers using sna 44 45 46 due to the characteristic of the influencing force of the indicator in the network these results may have important implications for the spread 8 of obesity that can start at a young age and in the long term have consequences in adulthood 46 47 48 in our data the regular habit of having breakfast was a protective factor against weight gain this finding leads us to reflect on the importance of breakfast reinforcing that its composition is generally associated with higher consumption of fruits vegetables milk and whole grains 4849 this may explain its association with lower chances of overweightobesity in our study unhealthy eating practices the availability of highcalorie foods and the easy accessibility of these foods have been recognized in studies as contributing to the growing trend of obesity 50 51 52 furthermore studies show that ultraprocessed foods contribute to the diets of adolescents in many countries and represent a nutritional profile consistent with an increased risk of obesity 5354 corroborating our study which found that unhealthy food patterns composed of processed foods were related to greater chances of obesity in adolescents a limitation of this study is the homogeneity of the sample as the data collection took place in only one school thus the results found cannot be generalized nevertheless other studies have a similar sample 52143 given the small sample size the wide confidence intervals for some variables limit the precision of our estimates such limitations however do not invalidate the study because many alters were mentioned in the network allowing significant variability in the social network analysis further the a posteriori power tests analysis indicated reliable results in addition relying on adolescent selfreport data might have also given bias which is not circumventable in this kind of study nonetheless this study presents strengths it examines social networks food patterns and physical activity and associations with being overweightobese in high school students from rural northeast brazil our study not only focuses its analysis on the network of friends inside the school but also covers the family network and the networks of friends outside the school in addition it provides relevant information that can contribute to public policies aimed at being overweightobese providing a new approach to intervention to this public health problem future studies should consider collecting data on aspects related to the environment surrounding sports facilities and places to buy food close to schools that can influence the behaviors of adolescents concerning their lifestyles associated with being overweightobese studying urban schools to observe possible contrasts will also be important finally implementing interventions related to being overweightobese that use the methodology of complexagentbased systems based on the family network could reduce the prevalence of overweight and obesity in this population conclusions the research showed that social networks in a sample of adolescents in a rural area in brazil were mainly defined by family networks and friends inside and outside school with the most significant network being the family in addition the network identified representatives with a high degree of centrality and prestige with the power to disseminate obesogenic habits unhealthy food patterns were also directly associated with overweightobesity in the context studied the results showed that interventions are necessary to reduce overweightobesity in adolescents considering both the network structures in disseminating overweightobesity and food patterns consumption raising awareness of a healthy diet and lifestyle that adolescents will maintain until adulthood data availability statement data described in the manuscript code book and analytic code will be made available upon request pending application and approval informed consent statement consent was obtained from all subjects involved in the study

the objective of this study was to evaluate the social network food patterns physical activity and their associations with overweightobesity in adolescents from a school in rural brazil students from a rural school in northeast brazil n 90 completed questionnaires on sociodemographic characteristics food consumption physical activity and a name generator social networks were constructed using students social proximity ties principal component analysis was performed to determine food patterns and logistic models were used to investigate variables associated with overweightobesity most participants were girls 629 and the proportion of overweightobesity was 30 among adolescents students cited 2070 people from their networks family friends at school friends outside of school and others among them the family had the highest degree of influence 61 in the network and had the most shared meals with adolescents 47 adolescents perception of their family members body size as obese compared to normal or underweight was prevalent 51 adolescents with unhealthy food patterns were 72 more likely to be categorized as overweightobese and eigenvector centrality was also associated with overweightobesity or 588 95 ci 1083203 adolescents presented a social network with strong family influence in which a high percentage of overweightobesity was observed adolescents with high eigenvector centrality were more likely to be in the overweightobesity category additionally overweightobesity was associated with unhealthy food patterns in the family network

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background the world population is made up of slightly onequarter of young people 1 in developing countries this group constitutes 32 of the population 1 and is faced with several neglected health problems including sexual and reproductive health problems in nigeria about 261 of the population is within 1224 years 2 nineteen per cent of the young people had begun childbearing 3 and are more likely to experience adverse pregnancy outcome than those who delayed childbearing moreover the incidence and prevalence of sexually transmitted infections are high among young people aged 1524 years 45 in 2018 510000 young people between the ages of 10 and 24 were newly infected with hiv of whom 190000 were adolescents between the ages of 10 and 19 years 6 young people are also at risk of other srh problems such as unsafe abortion early marriage and sexual violence they are exposed to these problems mainly due to their unhealthy sexual behaviours such as early sexual debut multiple sexual partners and unsafe sex 7 access to and utilization of sexual and reproductive health services are essential for the prevention of sexual and reproductive health problems and diseases though availability and accessibility of srhs are still poor in developing countries 89 including nigeria the little services that are available and accessible are underutilized by young people 1011 yet there is an increase in the incidence and prevalence of srh problems and diseases among them such as teenage pregnancy unsafe abortion sexually transmitted infections hiv and aids in subsaharan africa 12 young people are supposed to make effective use of these services because the services are meant to promote the sexual and reproductive health of every individual the utilization of health services is measured based on health outcomes and the percentage of persons that use the services 13 the significant impact of srhs utilization can be observed in reproductive health outcomes such as pregnancy and birth prenatal and neonatal mortality maternal mortality sexually transmitted infections and hiv and aids and complications of unsafe abortion 14 since abortion is not legalized in nigeria the world health organization stated that nearly 20 of all global maternal deaths happen in nigeria 15 with the risk higher among adolescent girls 16 suggesting that young peoples use of srhs is low many factors could determine the utilization of srhs in nigeria despite efforts to make srhs available at the primary healthcare facilities these factors which are referred to as predictors in this study range from social personal psychological and health system factors the level of secrecy accorded to sexuality in some parts of nigeria with its direct and indirect implications makes it difficult for sexually active young people to freely access and use srhs exposing a high percent of them to stis 17 it is therefore important to study the perceived predictors carefully to inform health professionals and policymakers which would enable them to understand the srh challenges the young ones are facing and explore possible ways of addressing them for this study predictors were studied under the following subcategories sociodemographic psychocultural and health system factors to find out if they predicted young peoples utilization of srhs sociodemographic factors include age gender level of education religious affiliation location living status marital status economic status research has linked sociodemographic factors and young peoples utilization of health services 1819 moreover ones cultural and personal beliefs may influence the individuals perception of accessing and using health services psychocultural refers to the interaction of psychological and cultural factors in the individuals personality or the characteristics of a group 20 psychocultural factors in this study refer to those cultural beliefs or values that affect the psychology of the young one in seeking or using srhs in enugu state psychocultural factors included the belief that discussing sexual issues is a taboo fear of stigmatization or embarrassment based on cultural beliefs fear of meeting their parents or people they know in the clinics fear of being labeled a prostitute by community members fear of not getting married later in life fear of being barren and other cultural beliefs regarding the use of srhs by youths for example in some societies most people assume that providing srhs for the youth like the provision of sexuality education and contraceptives promotes promiscuity these fears and burdens can limit adolescents use of srhs and could result in stigmatizing youths that are bold enough to access and use available srhs 21 furthermore health system factors such as availability of quality reliable services the proximity of the facility to users cost of services lack of privacy and confidentiality long waiting time using services with adults and the attitude of service providers were assessed as predictors of young peoples utilization of srhs the nearer the facility to the users the higher their level of access and utilization geographical access therefore influences service utilization 922 the main objective of the present study was to determine if these factors predict the utilization of srhs among young people in enugu state this has become necessary because such prediction studies are lacking in the state while there are observed low utilization of health services among young people in nigeria we used young people and young ones interchangeably in this study methods study area design and sampling techniques mixedmethod research using crosssectional design was conducted in enugu state nigeria one thousand four hundred and fortyseven young ones were randomly sampled through a multistage sampling procedure indepth interviews and focus group discussions were conducted the first phase of this study which focused on availability and accessibility of srhs had been published 9 details of the study area design and sampling techniques are described in the study 9 data collection procedure processing and analysis a questionnaire indepth interview guide and focus group discussion guide were used for data collection the utilization of srhs was measured using two sections of a questionnaire that was developed for a big project section a elicited information on the sociodemographic characteristics of the respondents while section b elicited information on the utilization of sexual and reproductive health services which include sexuality education family planning services safe motherhood services postabortion care and prevention and treatment of stis and hiv and aids section a of the questionnaire and part of the idig and fgdg which elicited information about the accessibility of srhs have been published elsewhere the chisquare statistic and logistic regression were used to test the association at 05 level of significance other details about data collection processing and analysis are described in the published article outcome variables were measured dichotomously respondents were asked to indicate yes if they have used or helped another young person use the services otherwise no explanatory variables include sociodemographic psychocultural and health system factors the variables were categorically measured sociodemographic variables were gender age level of education living status location and income status the psychocultural variable was measured by the cumulative of responses to questions related to cultural beliefs and fear such as the belief that discussing sexual issues is a taboo fear of stigmatization or embarrassment based on cultural beliefs fear of meeting their parents or people they know in the clinics fear of being labeled a prostitute by community members fear of not getting married later in life and fear of being barren while health system variable was measured by the cumulative responses to questions relating to the health facility and service providers such as availability of quality reliable services the proximity of the facility to users cost of services lack of privacy and confidentiality long waiting time using services with adults and the attitude of service providers results table 1 shows the sociodemographic characteristics of the respondents one thousand four hundred and fortyseven young people between the ages of 12 and 22 years with a mean age of 169 years responded to the questionnaire more than half of the respondents were females while 429 were males slightly more than half had secondary education the majority of the respondents lived in rural areas and most of them were living with their parents the majority had a monthly income of less than 500000 9 table 2 shows that the overall percentage total of 382 utilized srhs the table shows that more than half of the respondents reported using sexuality education services 309 use family planning information and services 365 use safe motherhood services 236 use postabortion care services and 403 use services for the prevention and treatment of stis and hiv and aids table 3 shows that age level of education income psychocultural and health system are significantly associated with sexuality education utilization while gender age level of education location psychocultural and health system are significantly associated with the utilization of family planning the table further shows that gender age level of education psychocultural and health system are significantly associated with safe motherhood services utilization age level of education location income psychocultural and health system are significantly associated with the utilization of postabortion care while income psychocultural and health system are significantly associated with the utilization of services for the prevention and management of sti hiv and aids table 4 shows that sociodemographic factors of gender male older age and lower income were significantly associated with lower odds of srhs utilization while tertiary education and living in school were significantly associated with higher odds of srhs utilization similarly psychocultural and health system factors were significantly associated with higher odds srhs utilization qualitative data data generated through indepth interviews using the idig reveal that only 9 out of 27 interviewees agreed that they have used other srhs apart from sexuality education which 26 of them use in the schools churches and at homes in the words of some interviewees i have never used any of these services i have only used sex education services i dont use them because i dont think i need them i did not use any of them … …… … though last year during youth week in my church a health provider came and thought us about sex education yes i used only sexuality education and services for prevention and management of stis and hiv and aids however many of these interviewees did not want to reveal the specific services being used few participants in the focus group discussions using the fgdg admitted using srhs apart from sexuality education most males were of the view that srhs is mainly for females except for sexuality education and services for prevention and management of stis and hiv and aids i have not used any of these services they are only for females or married people it is true p1 is correct yes at times we get some during youth week seminars and school i was tested for hiv last year this implies that the majority of the participants use sexuality education and services for the prevention and management of stis and hiv and aids only discussions the utilization of sexual and reproductive health services among young people is essential to reduce the prevalence of srh problems in developing countries 2324 which is posing a challenge to the actualization of sdg 3 determining the factors that make young people use or not to use srhs is very important in designing interventions to promote young peoples srhs utilization we utilized mixed method research because we have learned from experience that triangulating multiple methods of data collection is better than using a single method especially when collecting sensitive data such as sexuality information our study found out that some sociodemographic psychocultural and health system factors could be used to predict the utilization of srhs among young people the utilization of srhs among young people was low sexuality education was the only srhs utilized by slightly more than onehalf of the respondents the finding may be because these services apart from sexuality education were normally provided in the general health facilities which are not so comfortable for young people previous studies in other countries also reported 1925 low utilization of reproductive health services among young people similarly qualitative data generated through indepth interviews revealed that very few of the participants agreed that they had used other srhs apart from sexuality education which the majority of them used in the schools churches and homes however many of these interviewees did not want to reveal the services being used which was not surprising to us because of the secrecy accorded to sexual issues generally and particularly in the study area few participants in idi and fgd admitted using srhs apart from sexuality education the utilization of sexuality education safe motherhood and postabortion care services was associated with sociodemographic factors of age and level of education there was an association between income level and sexuality education postabortion care and services for the prevention and management of stis hiv and aids while utilization of family planning services was associated with location level of education and living status younger respondents utilized sexuality education more than the older respondents this could be because younger ones are still in school where sexuality education is taught and the majority of the young people revealed in qualitative data that they used sexuality education services only in schools the finding is consistent with 11 who reported that age is significantly associated with srhs but the finding differs from nisar and white 26 who reported no association between age and antenatal care utilization surprisingly young people with no formal education used all the srhs except sexuality education more than their counterparts with any formal education although some previous studies reported an association between level of education and utilization of srhs 26 27 28 the common report has been that those with a higher level of education utilize the services more than those with no formal education all the srhs were associated with psychocultural factors qualitative data revealed that young people in the study area believed that services under family planning are taboo for unmarried young people the cultural belief is that family planning services are for married couples only they also believed that srhs will make youth promiscuous and barren later in life these beliefs make some young people feel ashamed and afraid of using srhs this finding is consistent with previous research 29 which reported that cultural beliefs and practices affected utilization of maternal health services and one of the reasons young people do not use contraceptives includes feeling embarrassed or ashamed to use or purchase contraceptives 21 similarly there is an association between all the srhs and health systems factors the finding could be because there is a lack of youth clinics or units which are expected to have specially trained service providers that provide youthfriendly srhs information from the qualitative data revealed that most interviewees and fgd participants said that the pattern of service delivery like long waiting hours lack of privacy the attitude of health providers and not being youthfriendly in services provision were the major health systems factors that influence their use of srhs the finding is consistent with cheptum et al 29 who reported that lack of facilities inadequate staffing and negative staff attitude were associated with access and use of health services anusornteerakul khamanarong khamanarong and thinkhamrop 30 reported that the health service system is one of the important factors influencing the management of youths reproductive health services the finding showed that the male gender older age and lowerincome were associated with lower odds of srhs utilization while tertiary education and living in school psychocultural and health system factors were associated with higher odds of srhs utilization these show that sociodemographic factors psychocultural and health system factors could be used to predict young peoples utilization of srhs the findings agree with previous studies that reported some of these demographic factors as predictors of srhs utilization 2631 previous studies also reported psychological and cultural factors as significant predictors of utilization of srhs 2932 the common reason young people do not use contraceptives included feeling embarrassed or ashamed to use or purchase condoms or any other contraceptives 33 additionally the belief that discussing the sexual issue is a taboo prevents parents from rendering ageappropriate sex education at home limiting young ones from getting basic information about sexuality early enough 11 health systems factors such as providers attitude having a good and friendly relationship with the youth keeping the clients information confidential among others determine youths access to reproductive health and make youth reproductive health services successful the proximity of health facilities available services and the good reputation of the providers were the main predictors for choosing health facilities 3435 conclusion the study concluded that some sociodemographic psychocultural and health system factors are predictors of young peoples utilization of srhs these predictors could be addressed through home sex education regular training of health care providers on youthfriendly services delivery and policy reforms limitations the study utilized the crosssectional design therefore cannot assume cause and effect association the legal age of consent was a challenge because it was difficult to convince the parents of young people below the age of 18 years even when the young people were ready to participate on the other hand some young people declined their participation because their parents were to give consent nigeria is a multiethnic country and this study was conducted only in one state dominated by one ethnic therefore our findings may not be generalized to population or states dominated by other ethnic groups with different beliefs and perceptions about sexuality authors information authors are academic staff and researchers at the university of nigeria nsukka competing interests the authors declare that they have no competing interests

background sexual and reproductive health services srhs are essential for the prevention and control of srh problems among young people and the achievement of sustainable development goal 3 these services may be available but certain factors interfere with their access and utilization by the young people this study sought to determine factors that predict the utilization of srhs among young people in enugu state nigeriathe study adopted mixedmethod research employing a crosssectional research design the population of the study comprised young people between the ages of 12 and 22 years a multistage sampling procedure was used to select 1447 young people used for the study a questionnaire indepth interview and focus group discussion were used for data collection percentages chisquare and logistic regression were used to analyse quantitative data while qualitative data were thematically analysed using nvivo software results sociodemographic factors of gender age education income and living status p 05 were significant predictors of utilization of srhs psychocultural and health system factors p 05 were also significant predictors of utilization of srhsthe study concluded that some sociodemographic factors of gender age level of education income and living status psychocultural and health system factors can be used to predict young peoples utilization of srhs these predictors could be addressed through home sex education regular training of health care providers on youthfriendly services delivery and policy reforms

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introduction an everincreasing volume of evidence documents that external social conditions such as socioeconomic inequality affect individual health to ultimately increase morbidity and shorten life although genetic makeup may dictate ones basic endowment of individual resources social entitlements and deprivations likely act as switches that turn on or off the bodys ability to maximize those inherent assets most widely studied of these switches has been the association between socioeconomic status or wealth and health ses may be measured at the individual level by examining relative income educational attainment occupational class or deprivation 1 it can also be examined across groupings as large as nations by assessing income inequality that is the gap between the percent of the population and the percent of that populations earnings relative to the whole 2 regardless of the measure in general lower ses brings greater morbidity and mortality we could find no studies of ses and overall health that included a measure of perceived gender equity as an independent explanatory variable by gender equity we mean fairness and justice in the distribution of benefits and responsibilities between women and men the concept recognizes that women and men have different needs and power and that these differences should be identified and addressed in a manner that rectifies the imbalance between the sexes in studying whether the effects of ses are modified by the constraints of race and ethnicity in the uk cooper was able to indirectly hypothesize that gender inequity is bad for the health of some women 3 she examined whether the links between ses and selfreported health varied by sex finding that they did not among white men and women but for ethnic groups particularly those from pakistan and bangladesh being female added to the disadvantage of economic deprivation although no explicit measure of gender inequity was used in this study the variation observed could indicate that greater acceptance of gender inequality that is of sex disparities in rights decisionmaking or access to and control of resources at the group level may have detrimental health effects on women effects that intersect with and magnify those of ses alone socioeconomic and gender inequities are thought to intersect interact and possibly confound each other however research has primarily examined the effects of disparities across but not within households 4 in this study we explore the independent and relative impact of socioeconomic and perceived household gender inequities on selfreported health outcomes testing various measures and models initial key research on ses and health was blind to sex differences 5 subsequent enquiry suggested that not all measures of ses have a common meaning for men and women while ses alone is generally more closely linked to health outcomes in men than women measures of lack of material resources and relative deprivation tend to show a linear inverse relationship with health for both sexes 167 the combined ses of household members may more accurately reflect lived economic status than do individual measures similarly in settings where male incomes exceed female for women who have a male partner his occupational status or the occupational class that is dominant within the household can be a better predictor of health outcomes than is her occupation 389 for men with female partners occupational status of that partner generally does not explain male health status the difference in observed effect depending on sex means that use of individual occupational status as a measure of ses may have different meanings for men and women and can therefore be problematic equally challenging is the meaning of individual educational attainment or individual income although these may measure ses in men and single women the contribution of partners incomes and educational status has a significant bearing on the ses of women who cohabit with male mates 8 measures of relative deprivation that is of inability to afford those goods and activities that are typical of a specific society at a given time appear to maximize accuracy and minimize gender bias without necessitating stratification of research data by marital status 10 dissecting the differences between women and men in the relationship between relative wealth and health may foster greater understanding of how social determinants translate into individual health outcomes within the past two decades social epidemiologists have begun to focus on how the health effects of ses vary by sex in men the observed association between occupational class and health appears to be mediated by psychosocial as well as physical conditions in the workplace and by job security 11 however among women but not men domestic workload and perceived control at home have a significant impact on health while both sexes are disadvantaged by household material deprivation 12 in general it would appear that a sense of relative deprivation has a negative impact on health regardless of gender for men individual ses intertwined with workplace status and control seem central whereas for women household ses and individual control or equity at home may be key determinants of health informed by the literature reviewed above our study will use a variety of measures of socioeconomic status including a deprivation scale to explore relative contributions of these to self reported health of men and women unlike the above literature the relative contribution of perceived gender equity will be identified not solely by determining whether the relationship of interest is different for women and men but also by including an explicit measure of gender equity among the independent variables methods results table 1 shows that men had a lower education level than women but also experienced less financial deprivation and less gender inequity no significant differences between men and women were found for current suboptimal selfrated health at age 16 girls had had more somatic depressive and nervous symptoms than boys table 2 examines the associations between various independent variables using different models in a logistic regression with suboptimal selfrated health at age 42 as the outcome bivariate correlations for each independent variable except sexgender with suboptimal selfrated health at age 42 are statistically significant low education and lack of financial strain remain significant in all models perceived gender inequity becomes insignificant when financial strain is added to the model controlling for the effect of poor health at age 16 does not influence results when interaction terms for pairings of independent variables are all included in the analysis none appears to be significant however sexdisaggregating the data exposes different associations between the various social determinants and health outcomes for men and women financial strain and low education the proxy measures of ses are significantly related to poorer health outcomes among women but not men for men the only precursor of poorer health is perceived gender inequity discussion we do not know the direction of the perceived gender inequity measured that is whether respondents held positions of power or powerlessness relative to their partners it is tempting to expect that social norms prevail and men hold power when inequities are identified however this would be an assumption our findings speak only to the lack of association for women and statistically significant association for men between living within a relationship where power imbalances exist and selfreported health and not to the individual health effects that might arise from position within that imbalance therefore although the question regarding gender inequity did not specify the direction of that inequity our analyses identify that there are sex specific aspects to the health effects of perceived gender inequity at home the selfrated health of those women studied appeared to be somewhat insulated from harm arising from domestic inequities whereas mens health suffered when inequity existed our findings replicate others showing that in a variety of settings masculine behaviour by either women or men may decrease and detract from the ability to neutralize deleterious external inputs 20 sweden is ranked as the most gender equal country in the world a macrolevel characteristic that may have multilevel effects including an impact on individual health 21 nevertheless at the individual level there is research by rothstein suggesting that swedish women continue to take greater responsibility for domestic work and childcare and that this may affect their roles and positions in the workforce 22 this also suggests although does not ascertain that women may be in positions of disadvantage when describing perceived gender inequities in the current study our finding that a perception of domestic gender inequity is more frequently reported by women is in keeping with rothsteins research although a relative lack of financial strain amongst females may mean that domestic inequity does not translate into workplace disadvantage across the relatively homogeneous population studied we have identified some sex differences men had significantly lower educational attainment than did women but were less likely to suffer from financial strain this could suggest that in this setting financial strain is more closely aligned with the combined educational status of the household than each individual within it or that male occupational remuneration is less linked to education level than is the case for women when men and women are considered together higher education and lack of financial deprivation are directly associated with selfreported health while sex and perceived gender equity are not the grouping of results for both sexes obscures significant sex differences and illustrates the importance of sexdisaggregating data including all interaction terms in the regression in an attempt to identify effect modification of sex on the relationship between the other independent variables and table 1 distribution of variables used in the analyses among men and women health outcome also yields no statistically significant findings it is only when data are sexdisaggregated and reanalyzed separately for women and men that sex specific relationships between each of education financial deprivation perceived gender inequity and health emerge in contrast to existing research our findings indicate that individual education level is directly associated with health for women but is not significant for men the association for women is strong enough that in the collective model it masks a lack of significance among males there are a variety of possible explanations for our findings the equalizing effect of social programs in sweden may correct for economic disadvantage of lower education for both sexes incomes derived from traditional male blue collar jobs may exceed those received by women of the same class and education level women overall had higher educational attainment than did men so that in contrast to findings in more traditional societies household educational status that accounts for a family income benefit derived from having a female partner with higher education may more accurately represent lived ses among men than among women household education level is unavailable therefore it is not possible to test whether in the current swedish context of egalitarianism a womans educational level may have some bearing on the ses of her partner while his educational attainment has no effect on her ses 78 lack of financial strain also appears to confer health benefits in the aggregated multivariate model however disaggregation shows this benefit is only significant for women again the association between financial deprivation and poorer health overall may speak to the equalizing influence of swedens social programs that do not correct income imbalances but minimize their effects the sex difference in effect may be the outcome of a partial reversal of traditional sex roles and gendered opportunities in this egalitarian environment to the best of our knowledge ours is the first study to include an explicit indicator of perceived gender inequity in ones relationship and consider whether it changes the association between ses and selfreported health on the whole a significantly greater proportion of women reported gender inequity when considered alone gender inequity predicted poorer health outcomes overall however this association disappeared after adding financial deprivation sex and education to the model once again the lack of observed effect at the collective level masked a sex difference revealed when the data were sexdisaggregated gender inequity was predictive of poorer health in men independent of measures of ses but was of no predictive value in women in contrast to most existing findings we have shown that for men characteristics of the home environment had an impact on general health whereas socioeconomic measures did not and that the reverse was true for women while somewhat counterintuitive these findings may reflect the egalitarian nature of swedish society and a loosening of rigid and traditional sex roles in parenting and the workplace backhans has shown that when swedish women move into conventionally male occupational roles their longevity advantage diminishes 23 perhaps a similar reversal of fortune explains our data as womens options expand to include those historically restricted to men the social determinants of female health make a similar shift toward those previously associated with men conversely as men take on more female roles such as parenting the inputs that shape their health may align more closely with those traditionally associated with being female 24 our findings are consistent with coopers 3 suggestion that greater acceptance of gender inequity at the group level may have adverse health effects for women in the swedish environment where gender equality is valued this cultural norm may offset or negate the deleterious health effects of individual gender inequities for women a recent study also using the northern swedish cohort identified a direct association greater for men than women between perceived gender inequity and psychological distress 25 while we found that womens selfreported health is not harmed by gender inequity a sense of unfairness within ones relationship may have psychological costs for both women and men costs that may translate into a perception of poorer physical health among men but do not undermine womens sense of physical wellbeing our research has some limitations the population studied is relatively homogeneous limiting generalizeability while conferring robustness since confounding factors such as differences in religion culture or access to social programs are not operative the meaning of deprivation or financial strain is necessarily contextual and not absolute for example inability to go to the cinema would not have universal meaning but was part of the composite measure used in this research however deprivation is by nature a relative measure it is relative deprivation rather than absolute income that seems most meaningful in existing research and hence we have chosen it as a measure of ses it is also a measure that has been shown to have meaning for men and women as discussed earlier our measure of gender inequity was subjective and did not identify the direction of that inequity lastly there may well be unmeasured characteristics such as occupation health behaviours aspects of resiliency etc that explain some of the observed differences in selfreported health in sweden there is a relatively high degree of familiarity with and acceptance of the value of gender equality as a result direct questioning about gender fairness in ones home environment is feasible the large proportion who responded to this question among the northern swedish cohort likely implies that participants understood the meaning of domestic gender equity those few existing studies that have examined whether gender equity is associated with health have relied on proxy measures of equity such as sex differences in selfreported time spent on housework or parenting the choice of which measures to use in future research should be informed by a realistic assessment of participants fluency with concepts of gender and equity and will therefore vary from country to country our aim was not to define an absolute measure of a gender equal or unequal relationship but rather to look at whether individuals perceptions of inequities had some bearing on perceptions of health our findings do suggest the importance of considering selfreported inequities within the home environment as explanatory factors for physical wellbeing this is a first study of the general health effect of domestic gender inequity considered in conjunction with ses while higher education and less financial strain predict better selfreported health among women the pattern for men is noticeably different only gender inequity in ones primary relationship is associated with poorer male health gender inequity at the individual level has less impact on health than the wounds caused by financial deprivation among women but not men the gender difference is interesting needs greater exploration is somewhat in keeping with multilevel studies of less gender equal societies cited earlier and showing that men have poorer mental health outcomes than women but is counterintuitive it would nevertheless appear that in a society that values equality aspects of female gender roles increase immunity to while being male diminishes resilience in the face of gender inequities in ones primary relationship it would also appear that the associations between gender and health are only revealed when data are sexdisaggregated supporting information appendix s1 relevant survey questions

introduction limited existing research on gender inequities suggests that for men workplace atmosphere shapes wellbeing while women are less susceptible to socioeconomic or work status but vulnerable to home inequities methods using the 2007 northern swedish cohort n 773 we identified relative contributions of perceived gender inequities in relationships financial strain and education to selfreported health to determine whether controlling for sex examining interactions between sex and other social variables or sexdisaggregating data yielded most information about sex differences results and discussion men had lower education but also less financial strain and experienced less gender inequity overall low education and financial strain detracted from health however sexdisaggregated data showed this to be true for women whereas for men only gender inequity at home affected health in the relatively egalitarian swedish environment where women more readily enter all work arenas and men often provide parenting traditional primacy of the home environment for women and the work environment for men in shaping health is reversing such that perceived domestic gender inequity has a significant health impact on men while for women only education and financial strain are contributory these outcomes were identified only when data were sexdisaggregated

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introduction the frequency of weatherrelated disasters is increasing mainly because of the continuous increase in floods and storms with floods alone accounting for 47 of all weatherrelated disasters between 1995 and 2015 affecting 23 billion people in the world disaster has caused significant damage and impacted peoples health and social life natural disasters are a substantial threat to health and human security sustainable development goals 20152030 have led to greater coordination and coherence towards standard climate change and disaster prevention and mitigation goals community resilience is essential for community recovery after disasters and building community resilience regularly leads to preparedness community resilience has recently been a novel approach to public health emergency preparedness and response and has become an essential component of national policy community disaster resilience holds excellent promise as a guiding paradigm for promoting disaster risk reduction and enabling recovery from disasters by focusing on and investing in local capacity to adapt to a changing and uncertain environment social determinants of health are the conditions in the environments where people affect a wide range of health functioning and qualityoflife outcomes and risks examples of sdoh include safe housing transportation neighborhoods racism discrimination violence education job opportunities income access to nutritious foods and physical activity opportunities language and literacy skills from experience people often say that women are more vulnerable than men in times of disaster there are gender difference with women being the victims of many disasters genderbased gender roles are reinforced during disasters which increases womens workload disadvantages women in accessing reconstruction resources and human rights are less likely to be protected after disasters such as increased violence against women however it is important to note that women are not generally vulnerable to disasters and are resilient as they take on many roles women played a significant role in reconstruction after the great hanshinawaji earthquake the womens strengths include the fact that they had to create new relationships to provide food clothing and shelter that they developed horizontal relationships that were not bound by titles that they spun networks backed by trust between individuals and that in the process of collaboration between women in public and private sectors to create reconstruction systems networks became a driving force on the frontline the characteristics of disaster in latin america earthquakes and tsunamis account for the highest number of deaths followed by wind and flood disasters such as storms and floods in disasteraffected regions economic losses are significant making recovery and reconstruction more difficult especially in lowand middleincome countries the cost of damage also rises to 103113 billion in central america significantly affecting peoples lives and health regarding the medical human resources that influence the maintenance of peoples health it is noteworthy that nurses are not evenly distributed across the globe in the american region eightyseven percent of the regions nurses are located in brazil canada and the united states the difference in density depends mainly on income level with 91 nurses per 10000 people in lowincome countries compared to 1077 nurses in highincome countries thus latin america is a region vulnerable to geographical economic and healthcare human resources the situation in the republic of honduras which is located in the central american region is vulnerable to natural disasters such as earthquakes tsunamis hurricanes and volcanic eruptions the losses incurred between 1995 and 2015 are equivalent to 64 of the countrys gdp the land was hit by two hurricanes and a pandemic in 2020 in the republic of honduras the number of nurses who account for about 60 of the health professionals who play an essential role in the coronavirus disease 2019 response is less than 10 per 10000 people and there was a shortage of health professionals to address this situation the government has implemented a project to promote primary health care since 2013 in which doctors nurses and promoters form home health teams centered on health centers the relationship with social capital in the response of local residents to disasters including recovery and reconstruction has been described as an important factor in previous studies in recent years social capital continues to be a central mechanism through which community resilience reduces disaster impact and enhances recovery community resilience is used to describe a communitys ability to deal with crises or disruptions in all systemic phases of disaster risk management response recovery prevention mitigation and preparedness social capital is a valuable driver of disaster risk and vulnerability reduction and plays a contributory role in building peoples capacities the social capital assessment tool an initiative of the world bank and the adapted version of scat clear distinction is made between the structural aspect and the cognitive aspect the social capital community benchmark survey conducted by putnam and harvard university takes a multipronged approach szreter and woolcock create a scale that distinguishes between bonding bridging and linking social capital bonding is an aspect of inward social networks that reinforce exclusive identities and homogeneous groups bridging is an aspect of outward social networks between different social and ethnic groups that do not necessarily share similar identities and linking represents the norms of respect and trust associated with power and authority gradients there are the communities advancing resilience toolkit resilience performance scorecard to illustrate the dynamics of urban resilience and recovery and conjoint community resilience assessment measure as a component of community resilience ccram facilitates the estimation of an overall community resiliency score but furthermore it detects the strength of five important constructs of community function following disaster leadership collective efficacy preparedness place attachment and social trust there is a shortened version of the ccram10 a 10item selfreport questionnaire the aim of this study is to determine the factors that influence the status of community resilience in a rural area in the western part of the republic of honduras that experienced two hurricanes in 2020 during the covid19 pandemic and their relationship with social capital methodology approach crosssectional studies a crosssectional study is a research design that collects analyzes and examines data at a single point in time for a specific population in this study a crosssectional study was chosen to investigate community resilience in the aftermath of two hurricanes during the covid19 pandemic study population this study selected the lempira department of the republic of honduras for this study this department was identified as a target area for the strengthening systems based on the national health model project for 20132018 in the republic of honduras that promoted primary health care this study collected data from a total of 139 households in the community in lempira from august to november 2021 cluster sampling was used in this study all households under the jurisdiction of one of the ten health centers in lepaera city lempira department were included in the study based on the list prepared by the health center local collaborators facetoface interviews were done while visiting their houses the eligibility criteria for the survey were participants at least 18 years old and females who could respond to the questionnaires the purpose and significance of the study preservation of anonymity freedom to participate no disadvantages associated with nonparticipation and freedom to withdraw from this study were explained verbally to the participants and informed consent was obtained before the study was conducted ethical approval was obtained from the scientific research unit biomedical research ethics committee of the faculty of medicine of the national autonomous university of honduras and the research ethics committee of himeji university collection techniques in this study community resilience was the outcome variable the ccram10 was selected for this study as a measure of community resilience recovery from crisis as it relates to disaster recovery and reconstruction the ccram10 was assessed using the scale was backtranslated to confirm retaining the scales original meaning the cronbachs alpha was found within the acceptable level ie 08230950 in this study responses were rated on a 5point likert scale we chose the ccram10 methodology because it has identified factors that indicate community resilience including expert opinion and because ccram10 can provide information that will help residents and decision makers anticipate emergency challenges and plan based on the results of this study it was recognized as an indicator that could be used to identify community and resident characteristics for community building another scale in this study was social capital as an explanatory variable as a measure of social capital this study used szreter and woolcocks bonding bridging and linking social capital framework responses were rated on a fourpoint likert scale for the social capital scales indicators cronbachs alpha ranged from 075 to 0815 other measurements were sociodemographic characteristics including age gender education level marital status religion employment and years of residence similarly other variables included disaster preparedness and whether the damages by the two hurricanes in 2021 view the original survey analysis processing this study calculated the descriptive statistics such as frequencies percentages and means at first for the analytic study this study applied multiple regression analysis the statistically significant threshold level was set to p less than 005 data analysis was performed using jamovi version 2300 result basic attributes table 1 shows that the mean age of the respondents was 384 years the average length of residence was 379 years occupation is employee or housewife 130 people people had elementary schoollevel education 106 people higher education 24 people and none 9 people 127 people have a partner and 9 are single 113 people were catholic and 22 were none the household income is low at 97 people and on average 42 people regarding their health status 106 people have no chronic diseases and 29 people have chronic diseases and no problems the target population of this study is characterized by healthy housewives who have completed elementary school table 1 demographic data disaster prediction and preparedness in the area of residence table 2 shows that the types of disasters that were expected to happen in their place of residence were landslides floods hurricanes and earthquakes with almost all respondents expected landslides the response asked about their preparedness nearly all had done nothing 33． disaster experience table 3 shows that in the two hurricane disasters experienced in 2020 25 people experienced damage most of those affected were affected by landslides followed by damage to house roofs factors affecting community resilience to determine the factors that influence the status of community resilience in the aftermath of two hurricanes during the covid19 pandemic in this section to examine the impact of social capital and background information on general community resilience this study used general community resilience and its five components as objective variables and the explanatory variables multiple regression analysis was conducted using bonding social cohesion bridging social cohesion and political trust for social capital and year of residence and education level for background information no influence of other explanatory variables such as household income and marital status was found in the background information the possibility of multicollinearity was examined by vif and was determined to be less than 3 for all explanatory variables indicating that multicollinearity was unlikely to occur the coefficient of determination r² of the model was 423 and the adjusted coefficient of determination for degrees of freedom was 39 a total of five variables explained approximately 40 of the variance in general community resilience table 4 shows that the number of subjects in the model and the partial regression coefficients with a 95 confidence interval general community resilience the multiple regression model significantly explained the data 128 p 001 interpreting the partial regression coefficients the most significant estimate was 0 the results were significant bonding social cohesion bridging social cohesion political trust year of residence and level of education explanatory variables there was a positive association between bridging social cohesion political trust year of residence there was a negative association between bonding social cohesion and background information for none and elementary school in level of education leadership leadership includes general faith in decision makers specific faith in local leaders perception of fairness in the way local authority provide services and functioning of the community the results were significant political trust year of residence and level of education explanatory variables there was a positive association between political trust and a negative association between none and elementary school for level of education collective efficacy collective efficacy includes collective efficacy support involvement in the community and mutual aid the results were significant political trust year of residence and level of education explanatory variables there was a positive association between political trust of social capital and year of residence of background information and a negative association between none and elementary school for level of education preparedness preparedness includes family and community acquaintance with emergency situations and a view of the towns preparedness for emergency situations the variables bonding social cohesion bridging social cohesion political trust year of residence and level of education were significantly associated with preparedness bridging social cohesion and political trust were positively related with preparedness there was a negative association between bonding social cohesion and background information for none and elementary school in level of education place attachment includes emotional attachment to the community sense of belonging pride in community and ideological identification with the community place attachment the explanatory variables of political trust and background information year of residence and education level showed significant association with place attachment political trust and year area of residence were positively related there was a negative association between non and elementary school for level of education social trust social trust includes trust and the quality of relationships between members of the community the explanatory variables bridging social cohesion political trust year of residence and level of education were significant political trust and year of residence were positively related with social trust there was a negative association between the none and elementary school in level of education and social trust discussion disaster preparedness the most striking result of this study was the gap in actual preparedness and awareness of disasters in lempira to the question what have you done so far to prepare for disasters most respondents answered i have done nothing however most of the respondents answered agree to the following two questions my place of residence is prepared for emergencies and residents know what their roles are in an emergency on disaster preparedness in ccram10 one of the reasons for this is that instead of each household preparing for a disaster people trust the ability of local leaders trained in disaster response it is also likely that a part of the honduran culture believes that if you have walls and a roof over your head you will be able to survive a disaster many people do not want to leave their homes during a disaster this study believe this is because even when there are storms or floods they would rather die inside than leave their homes because of their culture in other regions several previous studies have reported disaster awareness in local communities of developing countries the moken an ethnic minority affected by the indian ocean tsunami had no concept of tsunami or disaster they saw the coming tsunami phenomenon as part of the flood myth laboon and by the oral tradition that when the tide suddenly recedes abnormally laboon comes they fled to higher ground their lives were saved a survey in bangladesh found that few people evacuate during disasters indicating a widespread fatalistic view of natural disasters among the local population other reasons for not evacuating included fear for the safety of property and livestock overcrowded shelters and unsafe places for women thus in considering preparedness as one of the components of local resilience peoples awareness of disasters varies and understanding the culture of each region is essential in enhancing preparedness and a culturally sensitive response is required in understanding the awareness of disaster preparedness this study have to know first how people in the community think about risk in australia a checklist has been developed to link efforts to understand peoples attitudes to behavior change as a first step they assessed their preferences and value priorities when at risk of being severely affected by disaster losses by gaining new knowledge in the form of stories concepts understandings narratives and data about key drivers of vulnerability from a broad range of people these stories and identified system patterns highlight the tensions and value conflicts among different parts of society and various roles within organizations and the other they highlighted how ideas could arise factors influencing community resilience the results of this study indicate that in general community resilience which integrates the five items the bonding social cohesion hurt community resilience while bridging social cohesion and political trust had a positive impact on community resilience the classification of whether social capital is conjunctive bridging or linking is important coupled social capital is a network whose members share similar background factors in terms of hierarchy raceethnicity etc or the resources members have access to within such a network bridging social capital is a resource that bridges across class raceethnicity and other social characteristics and is accessible between networks in lempira a rural area in the target region of the republic of honduras networks of remarkable homogeneity were a factor that lowered community resilience and bridging networks among heterogeneity were a factor that raised community resilience there are several possible explanations for this result in particular the fact that those around them are not prepared for disaster preparedness leads to their lack of preparedness causing homogeneity to drag them down in terms of disaster preparedness this can be described as a homeostatic bias where people around them are not doing it so they do not need to prepare themselves these behaviors during disasters are consistent with people are influenced by the evacuation behavior of those around them in evacuation behavior it can also be explained with the social contagion theory which states that peoples attitudes and behaviors are formed under the influence of others with whom they are directly connected as a proposed solution informing people that their evacuation behavior is influenced by the evacuation behavior of others around them and making them aware and aware that their evacuation behavior affects others around them will promote evacuation behavior this study can propose a way to convey messages that lead to disaster prevention behavior by utilizing the nudges the undrr defines a disaster as serious disruption of the functioning of a community or a society at scale due to hazardous events interacting with conditions of exposure vulnerability and capacity leading to one or more of the following human material economic and environmental losses and impacts a disaster is a situation that exceeds the response capacity of the area and requires assistance from outside sources it makes sense that bridging would be an effective tool for community resilience in the context of external relationships in situations that exceed the local response capacity to accept and receive support from outside sources bridging is a connection to the outside world that transcends generations and roles and can be interpreted as a weak tie novel information is more likely to be obtained from weak ties with low frequency of contact and high heterogeneity than from strong ties with a high frequency of contact and high similarity disasters are a place and a time in which relationships in peacetime and weak ties loose relationships with the outside world overlap the weak ties with the outside world may work effectively as external support political trust refers to the linking social capital in this study higher linking leads to higher community resilience 43． education and community resilience the community resilience for those with elementary school education was higher than for those with no education but not different from those with more than elementary school education there is no study about education and community resilience in honduras primary education is provided to children between 6 and 15 although there is a movement to make nine years of primary education compulsory a total of six years is currently compulsory compulsory education in honduras consists of one year of preschool nine years of basic education and two to three years of secondary education for a total of 12 to 13 years however students with poor grades repeatedly fail out of school and only 50 of children graduate from grades 1 to 6 of basic education in 6 years with some dropping out and the completion rate being 86 one of the purposes of compulsory education is to nurture people who can live in a world of i and the world of we it is essential to have a view of oneself not only about oneself but also about the people around one this study found differences between those who had compulsory education and those who did not the contrast between educational background and community resilience may be due to the difference between the world of i and we nurtured through compulsory education or the difference between the connection with other people and social skills limitations of the current study are that the study subject was limited to women and that information on culture was not taken therefore it is difficult to determine how gender and cultural background affect disaster preparedness and community resilience future research should be conducted from these perspectives población y salud en mesoamérica es la revista electrónica que cambió el paradigma en el área de las publicaciones científicas electrónicas de la ucr logros tales como haber sido la primera en obtener sello editorial como revista electrónica la posicionan como una de las más visionarias población y revista psm es la letra delta mayúscula el cambio y el futuro xxxx indexada en los catálogos más prestigiosos para conocer la lista completa de índices ingrese aquí conclusion in the community resilience of housewives in western honduras bonding worked negatively while bridging worked positively enhancement of bridging may work effectively as external support this study clarified the positive contribution of elementary school education to community resilience through fostering connection with others and social skills the results of this study suggest that local and national public policies can contribute to community resilience first based on the finding that the acquisition of bridging networks and political trust increase resilience we believe that creating an environment where governments residents and external organizations can communicate regularly and build bridging and linking networks will lead to increased community resilience second because the presence or absence of primary education completion has a significant impact policies to enable primary education completion should be strengthened this study gives a new insight into the relationship between social capital and community resilience acknowledgments the authors would like to thank our local collaborator maría fernanda castro flores and melissa valeska sevilla gonzález in the republic of honduras and the residents of lempira province for their cooperation in the survey this work was supported by jsps kakenhi grant number jp19h04354 authors contributions junko miyamoto conceptualization research formal analysis writing draft minato nakazawa methodology peer reviewediting declaration of competing interest all authors have no conflicts of interest to disclose

introduction building community resilience is an important part of disaster preparedness this study aims to determine the factors that influence the status of community resilience and their relationship with social capital methods data were collected between august and november 2021 by surveying a group of over 18yearold females in the republic of honduras where hit by two hurricanes and a pandemic in 2020 cluster sampling was used in this study and facetoface interviews were done while visiting their houses the conjoint community resiliency assessment measure ccram was used to examine community resilience score while the association between social capital basic attributes disaster preparedness and whether the damages by the two hurricanes in 2020 etc for statistical analysis we applied multiple regression analysis results bonding social capital was a factor that lowered community resilience and bridging social capital was a factor that raised community resilience the community resilience for those with an elementary school education was higher than those without education but not different from those with more than an elementary school education conclusions bridging social capital and completing primary education increased community resilience

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introduction research has demonstrated that having more social ties among drug users is linked to hiv risk behaviors including needle sharing and transactional sex 1 for example researchers show that drug users with greater social ties and social ties who use crack were more likely to share needles and participate in transactional sex than their counterparts with fewer social ties 23 moreover because drug use is highly criminalized many drug users experience discrimination including ostracism and rejection from social housing and employment opportunities 4 5 6 7 which may result in isolation from positive social ties in fact crawford and colleagues showed that drug users who experienced discrimination particularly because of their race had more highrisk social ties 6 social interactions are influenced by spatial patterns and proximity between individuals 8 however experiences of social discrimination within disadvantaged neighborhoods may isolate drug users into relationships with other drug users 46 9 10 11 the interaction between discrimination and neighborhood conditions may be shaped by inadequate housing and employment opportunities making the resources and social ties available pose an even greater risk for negative health consequences however there is a paucity of research assessing reports of discrimination by neighborhood characteristics and further assessing how discrimination and neighborhood disadvantage influence health 1213 and possibly health behaviors a study among nondrug using black women found an inverse relationship between racial discrimination and percent black in the neighborhood 13 thus it is possible that individuals in poorer neighborhoods and those with higher minority composition or racial homogeneity have higher levels of cohesion and a smaller chance of experiencing racial discrimination or identifying experiences of racial discrimination 1415 whereas neighborhoods with fewer minorities may present an increased opportunity for discrimination however it is unclear whether experiences of discrimination due to nonracial attributes are also less likely to occur or be perceived less in these neighborhoods researchers have argued that disproportionately fewer resources available in racially segregated neighborhoods promote stress and negative health behaviors 16 which could explain higher drug use and drug trade levels in these neighborhoods 16 for example previous studies using national data show lower levels of drug use among blacks however racially segregated neighborhoods and neighborhoods with higher concentrations of uneducated black residents are associated with increases in injection drug use and perceptions of drug trade among black residents therefore neighborhood conditions may pose an increased potential for developing relationships among drug users that facilitate drugusing behaviors and relationships 17 that enhance infectious disease risk given the potential role of neighborhood characteristics on experiences of discrimination and the availability of and isolation into drug use relationships this study will examine the role of neighborhood minority composition poverty and education level on the relationship of discrimination due to race drug use and prior incarceration with drugusing social ties we hypothesize that drug users who perceive discrimination who are also members of neighborhoods with either high minority composition low education levels or high levels of poverty would have more drugusing social ties methods we used data from the social ties associated with transition into injection drug use study for reports of discrimination and social ties and the 2000 us census data for characteristics of the participants neighborhood between august 2005 to january 2009 652 injection drug users and nonidus were recruited into the start study through a 1 prospective study design among nidus and 2 a crosssectional assessment among recently initiated idus only the baseline data collected from nidus and cross sectional data collected among idus were included in this analysis participants were recruited into start using targeted sampling strategies and respondent driven sampling a description of the tss employed for this study has been described elsewhere 18 briefly tss was completed in ethnographically mapped high drug activity new york city neighborhoods in harlem lower east side south bronx jamaicaqueens and bedfordstuyvesantbrooklyn rds a chain sampling referral strategy was used to enhance generalizability of the final sample and reach drug users who are harder to reach 1920 to be eligible for the start individuals had to be between the ages of 18 and 40 idus had to report injecting heroin crack or cocaine for four years or less and at least once in the past 6 months nidus had to report noninjection use of heroin crack or cocaine for one year or more at least 23 times a week in the past 3 months participant age was verified with a form of photo identification drug use was verified with a rapid drug test which detected opiate and cocaine metabolites in the urine and injection status was verified by visual track marks all participants were provided informed consent for study participation the study protocol and survey instruments were approved by the institutional review boards at columbia university and the new york academy of medicine participants were compensated 30 and provided with public transit cards for travel to and from each interview data collection participants completed facetoface intervieweradministered survey instruments survey instruments collected demographic information drug use patterns sexual practices mental health discrimination experiences and a social network inventory history spanning five years prior to study entry participants were asked to retrospectively identify individuals who were a part of their social network yearbyyear for each year participants identified an important event that occurred in their life to jog their memory of their social network during that year once all individuals in their network were identified for each year detailed information about the drug and sexual practices of each network tie was asked recalling behavioral histories have been shown to yield valid responses among idus using a tenyear reconstruction of behavioral histories 2122 this study uses a shorter period of recall of five years for the social network inventory history individuallevel variables to define the outcomes using the social network and behavioral history we added the total number of drug ties and separately assessed the total number of heroin and injection drug using ties who pose a particularly increased hiv risk 23 discrimination was collected by asking in your lifetime have you ever been discriminated against prevented from doing something or been hassled or made to feel inferior because of any of the following participants could respond yes or no to experiencing discrimination because of their age race sex sexual orientation poverty drug use having been in jail or prison religion mental illness physical illness or other this discrimination measure was modified from previous discrimination studies 2425 for drug using populations 7 discrimination due to race drug use and having been in jail or prison were the main exposures of interest as they are the three most prevalent forms of discrimination in drug using populations 26 consistent with previous studies 18 27 28 29 the following covariates were assessed as confounders age gender race education income in the past six months number of female sex partners and male sex partners age at sexual debut female condom use male condom use hiv testing lifetime depression measured using the cidi 30 injection status primary type of drug used and sampling strategy racial ethnic groups that were combined with nonhispanic whites included asian or pacific islander native american eskimo or aleutian black and hispanic mixed and other hispanics who identified as black were combined with hispanics rather than nonhispanic blacks since their reports of discrimination were more similar to hispanics suggesting that hispanic ethnicity may confer different interpretations meanings and experiences of discrimination 31 neighborhoodlevel variables participants were asked about the neighborhood including the cross streets in which they were recruited to participate in the study through tss or rds these neighborhoods were chosen as opposed to home addresses because most participants spent at least half of their time or more hanging out obtaining drugs and developing relationships with others in these neighborhoods 32 participant recruitment neighborhoods were geocoded to the 2000 us census tract using arcgis using summary tape files 2 and 3 from the 2000 us census we obtained data on neighborhood minority composition poverty and education for each census tract represented in the data we chose to assess minority composition using a proxy rather than formal measure of segregation to be consistent with previous studies 1213 assessing discrimination reports in neighborhood environments all neighborhood variables were categorized into tertiles based on the distribution of the variable cutpoints for neighborhood variables were 4404 4404 7578 and 7578 for percent black 2009 2009 4977 and 4077 for percent latino 3146 3146 4912 and 4912 for percent poverty and 7061 7061 7841 and 7841 for percent less than a high school education the neighborhoods in this sample have higher levels of minority residents and socioeconomic disadvantage compared to an average new york city neighborhood between 2000 and 2010 which was 255 black 286 latino and 186 of residents at the poverty level 33 we excluded participants who identified as transgendered and who were missing information on their census tract these exclusions yielded an analytical sample of 638 distributed across 143 census tracts statistical analysis descriptive statistics of the sample were calculated and included median and interquartile range for continuous variables and frequencies for categorical variables chisquare tests were performed to determine if significant differences in the prevalence of discrimination according to tertiles of each neighborhood characteristic was present unadjusted associations of each form of discrimination neighborhood characteristics and covariates of interest were assessed with respect to highrisk drug and heroin injecting ties using negativebinomial regression model to obtain the prevalence ratio variables with a statistically significant association with each outcome at p 005 level were included in the adjusted model each neighborhood variable was assessed separately as the estimates barely changed when they were included together twoway interactions between discrimination and each neighborhood characteristic identified as important in the bivariate analysis were tested in the fully adjusted models if an interaction was observed final models were presented showing the relationship between each form of discrimination with drug and heroininjection ties stratified by the neighborhood characteristic of interest after accounting for individual drug and sexual risk behaviors population average models specifying a negative binomial distribution were employed using the sas genmod procedure which took into account clustering of individuals within census tracts population average models avoid failure in meeting assumptions of independence between and within individual and hierarchical level observations needed for employing mixed models 34 all analyses were performed using sas version 92 35 results descriptive characteristics of the sample are described in table 1 the median age was 33 most participants were more likely to be black and hispanic male lower socioeconomic status and unmarried the majority of the sample did not inject drugs and used crack cocaine in terms of sexual behaviors the median number of female and male sex partners was 1 and 0 respectively most participants used condoms infrequently regardless of the partners gender the median age at sexual debut was 14 and most participants received four or more hiv tests in their lifetime most experienced depression in their lifetime and were recruited through rds participants were more likely to hang out in neighborhoods characterized with medium percentages of blacks latinos and residents living below the poverty threshold and low percentages of people without a high school education about 259 reported racial discrimination 328 reported discrimination due to drug use and 25 reported discrimination due to incarceration participants had a median of 4 drug using ties and 0 heroin injection ties lower levels of discrimination were reported among members of neighborhoods with a higher percent of blacks lower percent of latinos and lower percent poverty although no significant differences were seen there was not a clear pattern of discrimination reports by neighborhood education crude and adjusted associations between discrimination and recruitment neighborhood characteristics with drug and heroin injecting ties are shown in table 3 and4 with respect to drug using ties a significantly increased number of drug ties was seen among those who reported racial and drug use discrimination neighborhoods characterized by medium and high proportions of black residents were less likely to have drug ties on the other hand neighborhoods with medium and high proportions of residents without a high school education had significantly more heroin injecting ties in the adjusted models experiencing racial discrimination drug use discrimination and having a neighborhood with high proportions without a high school education remained significantly associated with higher drug ties with respect to heroin injecting ties those who reported discrimination due to their race drug and previous incarceration had significantly more heroin injecting ties similar to the drug ties neighborhoods characterized by medium and high proportions of black residents had fewer drug ties and neighborhoods with medium and high proportions of residents without a high school education had more heroin injecting ties in the adjusted model only racial discrimination and neighborhood education prhigh 222 remained significantly associated with higher heroin injecting ties heterogeneity of the association between drug use discrimination with fewer drug using ties and heroin injecting ties was significant for high proportion black neighborhoods when stratifying by percent black those who reported drug use discrimination in low and medium proportion black neighborhoods had significantly more drug ties than their counterparts reporting no discrimination the relationship between drug use discrimination and heroininjecting ties while not significant across the percent of blacks in neighborhood suggests that when compared to those reporting no discrimination those reporting drug use discrimination in low and medium proportion of black neighborhoods had greater heroininjecting ties while the opposite was true for those residing in neighborhoods with high proportion of black residents no significant interactions between racial discrimination and incarceration discrimination with drug nor heroin injecting ties and neighborhood education level were observed discussion we found that neighborhood social characteristics including minority composition and education are important in the relationship between discrimination and highrisk drug and heroininjecting ties neighborhood minority composition was a significant modifier in the relationship between drug use discrimination with drug and heroin injecting ties where individuals who experienced drug use discrimination in neighborhoods with more blacks had significantly fewer highrisk drug and heroininjecting ties this suggests that ideals of propriety that could isolate drug users in largely racial minority neighborhoods do not do so 36 it is possible that these neighborhoods are more respectful and less judgmental of other members of the neighborhood which may buffer against discrimination and the development of highrisk relationships neighborhood education level was not a significant modifier in the relationship between each form of discrimination with drug and heroin injecting ties to our knowledge this is the first study to investigate the influence of neighborhood on the relationship between discrimination and highrisk social ties our findings were consistent with the findings by dailey and hunt 1213 namely that members of neighborhoods with more blacks were less likely to report racial and drug use discrimination moreover those who experience racial discrimination in neighborhoods with fewer blacks reported more drug networks than those who did not experience racial discrimination since being a member of a more racially integrated neighborhood may increase the chances of encountering a racist or other discriminatory event and provide fewer social supports to buffer against these negative experiences further examination of the role of social cohesion in neighborhoods with a higher concentration of minority residents 14 should be further explored to support or challenge this plausible explanation 37 although neighborhood education was not a significant modifier in the relationship between discrimination and risk ties participants who were a part of neighborhoods characterized by lower education had significantly more drug and heroininjecting ties in a study assessing the social and environmental factors important in the drug use system having low educational attainment followed by being black and having low income were important indicators of living in a neighborhood where one could see drugs being sold see people high frequently and marijuana could be easily obtained 38 therefore given potential differences in exposure to drug activity by education level the role of discrimination in neighborhoods where residents have lower education still warrants further investigation particularly in a study with more variation and power to detect significant differences across neighborhood characteristics the social influence effect described by bearman explains that spatial context influence network relationships that infectiously transmit information about disease and social resources 39 this concept may be useful for understanding how context influences the development of highrisk relationships among drug users and the social physical and health risks that are transmitted because of these relationships understanding how the context of space place and social experiences shape disease risk is needed to better understand the progression of the hiv epidemic among this marginalized highrisk population and the progression of racial disparities in hiv this study has several limitations selfreport bias of drug use sexual practices and experiences of discrimination may have resulted in underreporting and thus underestimating the associations we observed moreover the accuracy with which participants identified the drug and sex practices of their network ties and identified all highrisk members of their network is unknown participants were likely to be different in terms of risk networks by recruitment strategy 40 but we adjusted for sampling strategy to isolate any effect based on differences in recruitment the use of rds sampling weights was also assessed in this sample but made no difference between the rds and tso populations measurement biases may have also affected reports of discrimination specifically discrimination was asked using one question which may not have been suitable to accurately capture experiences of discrimination further this measure of discrimination has not been validated among illicit drug users and therefore may be over or underestimated also related to measurement error this study utilizes 2000 us census neighborhood data while the individual data was collected between 2005 and 2009 therefore these neighborhood characteristics may not accurately reflect the composition of neighborhoods participants in this sample were a part of from 20052009 especially given rapid neighborhood changes due to gentrification while geronimus and bound found that bias related to changes in neighborhood socioeconomic predictors including education over a 10year period is minimal 41 it is also likely that drug users who relocate are most likely to relocate from deprived neighborhoods to similarly deprived neighborhoods 42 therefore the neighborhoods these participants are currently a part of likely reflect the same type of neighborhood in an earlier period other neighborhood limitations include the use of neighborhood tracts to delineate neighborhood boundaries that may not be accurate and congruency in parallel neighborhoods may have resulted in dependency and shared risk between neighborhoods 37 further because participants were recruited in high drug activity neighborhoods it may have limited our ability to detect important contextual effects also the use of participant hangout rather than home address may be a limitation but because these neighborhoods were such that participants spent most of their time and felt more connected to hangout neighborhoods are likely the most appropriate for a highly transient drug using population lastly since this analysis was performed on crosssectional data we are unable to determine temporality investigation of drug users experiences of discrimination and development of highrisk social ties over time and over the entire life course would provide temporality and strengthen this investigation few discrimination 43 social network 44 or neighborhood 37 studies have properly addressed issues of temporality nor examined the ways these social phenomenon may be related the results of this study suggest that neighborhood context may be important to consider when assessing discrimination and development of highrisk relationships a better understanding of how these relationships work will help in the development of tailored interventions that counteract the negative effects of social discrimination and ultimately hiv

objectivesocial discrimination may isolate drug users into higher risk relationships particularly in disadvantaged neighborhood environments where drug trade occurs designwe used negative binomial regression accounting for clustering of individuals within their recruitment neighborhood to investigate the relationship between highrisk drug ties with various forms of social discrimination neighborhood minority composition poverty and educationshow that experiencing discrimination due to drug use is significantly associated with more drug ties in neighborhoods with fewer blacksfuture social network and discrimination research should assess the role of neighborhood social cohesion

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introduction despite efforts to improve access to basic resources 768 million people rely on unimproved drinkingwater for daily consumption and an estimated 25 billion people lack access to improved sanitation facilities 1 the link between access to these basic resources and psychosocial outcomes is an emerging area of importance in global health research a study in ethiopia found that water insecurity was significantly associated with psychosocial distress 2 in bolivia wutich and ragsdale found that gender and the process of accessing water resources were significantly associated with emotional distress citing fear worry anger and bother 3 though the literature focuses on water insecurity sanitation access presents similar psychosocial risks particularly for women and girls in kenya henley and colleagues studied hair cortisol concentrations as a biomarker for chronic stress finding that concentrations were significantly higher in women who reported feeling unsafe while collecting water or accessing sanitation 4 in a study of mental health in urban slums in bangladesh gruebner et al found that elements of the built environment including access to a better toilet facility were significantly associated with high quality of life scores 5 in addition to navigating the built and physical environment for sanitation activities women face daily struggles with social status access to resources and social conflicts 6 7 8 time of day and privacy contribute to sanitationrelated stress 9 moreover women may have to cope with violence 1011 or sexual assault and rape 12 13 14 while completing sanitationrelated behaviors the present study seeks to add to the emerging body of research on the impact and determinants of sanitationrelated psychosocial stress data for this study are part of a larger mixedmethods study exploring womens relationship with sanitation in lowincome infrastructurerestricted settings in odisha india we build upon an initial grounded theory study that provided an empirically based conceptual understanding for srps among women of reproductive age in odisha 15 findings from this study suggest that sanitation encompasses a range of behaviors specific to the local cultural context including ritual anal cleansing menstrual management practices bathing and changing clothes prior to reentering the house after defecation sanitationrelated psychosocial stressors arise when women are unable to perform these behaviors free from worry fear or anxiety according to the conceptual model proposed in the study there are three categories of stressors environmental social and sexual genderbased violence stressors whose intensity is modified by a womans life stage living environment or access to sanitation facilities the current study aims to examine and compare stress as it relates to the specific sanitationrelated behaviors as well as explore the relative frequency and severity of individual stressors that contribute to srps among a sample of women in odisha recognizing that these sanitationrelated behaviors and stressors are contextually bound and dynamic in nature this analysis explores the differential impact of common psychosocial stressors on women living in different geographic settings and occupying differing social roles within the household and community we selected systematic data collection methodsa broad family of interviewing techniques originally intended to examine tacit knowledge in ethnography and cognitive anthropologyfor use in this study 16 these methods have been used to explore the boundaries and dimensions of specific cognitive domains that may be culturally defined or difficult to articulate such as kinship terms 17 or medicinal classifications 1819 and the internal systems of classification that individuals employ unlike openended interviewing or participant observations systematic methods entail asking all respondents the same questions and analyzing responses according to emic categorization rather than those imposed by the researcher for the purposes of this study the successive application of multiple systematic data collection methods allowed us to simultaneously examine the dynamic nature of sanitationrelated behaviors the relative degree to which these behaviors have contributed to psychosocial stress and the frequency and severity with which women in the sample and women like them in the broader population have dealt with psychosocial stressors methods study sites access to sanitation in much of india remains scarce and an estimated 44 of the population practices open defecation 1 however access to water and sanitation facilities may vary considerably by geographic context therefore we chose three resourcepoor geographic locations in odisha to reflect differing access to sanitation infrastructure as well as differing social and cultural practices urban slums rural villages and rural tribal villages with a large proportion of ethnically distinct residents in the urban site we interviewed women in two slums in bhubaneswar the capital of odisha some slum residents had access to either privately owned or public latrines but several participants still reported practicing open defecation rural women were selected from khurda district an agricultural region outside of bhubaneswar lowdensity rural tribal villages were selected from sundargarh district where about half of the population belongs to scheduled tribes recognized by the indian government 20 including oraron munda and kisan tribes in local terms tribal is used to describe both the geographically isolated regions and ethnic minority populations and we use the term tribal when referring to women from this site both sanitation practices and access to infrastructure vary here compared to rural areas in odisha and tribal women were therefore expected to face unique sanitation challenges sample and selection of participants we purposively sampled women from four life stages that are reflective of social and biological characteristics that influence a womans place in her household and community 1 adolescents unmarried women aged 1424 who had reached menarche and who lived with their parents and extended families 2 newly married women married two years or less the majority of whom had moved to a new social and physical geography to join the husbands family household 3 pregnant women women who identified as pregnant during data collection for whom pregnancy changed their household roles and created distinct physical needs for sanitation and 4 established adult women women between the ages of 25 and 45 who had been married more than two years and were not currently pregnant this sampling technique while not providing a proportionally representative sample of the population of women in odisha offered us an opportunity to assess life stagebased variance in srps in a small sample data collection volunteer community health workers affiliated with the asian institute for public health identified 20 women at each study site for participation in the study for a total of 60 participants our stratified purposive sampling strategy ensured equal representation from each of the four life stage groups of interest and a sample of latrine users and nonusers similar to the general population a team of four female interviewers trained in systematic data collection methods completed recruitment and data collection data were collected from april to may of 2014 we carried out structured interviews that employed two systematic methods pile sorting and ranking pile sorting methods have traditionally been used to understand the internal organization of domains through the generation of graphical multidimensional scaling plots 21 or hierarchical clusters 19 however the flexibility of these methods to examine the categorization and organization of a range of topics has resulted in innovative adaptations to for example explore abstract concepts such as stress in children 22 perceptions of posttraumatic mental health 23 and gender roles 24 ranking and rating techniques have been used to develop measurement tools for wealth and wellbeing reflective of local understandings of economic security 2526 and as participatory tools to engage residents in identifying and prioritizing needs in their communities 27 structured interviews began with basic demographic questions about the womans household followed by a data collection module on sanitation behaviors and one on stressors for behaviors we identified a local taxonomy 28 of sanitationrelated behaviors from our initial qualitative study 15 that included defecation urination menstruation postdefecation cleaning postdefecation bathing changing clothes and carrying water for use in sanitation field staff verbally presented participants with seven index cards each labeled with one of these specificsanitation related behaviors and explained each card to the respondent as interviewers introduced each card women indicated if the behaviors were part of their typical routines if not applicable the card associated with a behavior was set aside and excluded from further data collection in the interview next interviewers asked women to rank stress associated with each behavior most stressful to least stressful using a quicksort ranking method 16 in which respondents organize items along a specific continuum the rank order of cards was read back to the participant and recorded by the interviewer next the interviewer shuffled the cards and asked respondents to rank behaviors by freedomfrom the behavior they had the most freedom to choose when and how to practice to the least freedom rank order was again recorded for stressors we presented women with index cards labeled with specific sanitationrelated stressors and challenges identified in previously conducted indepth interviews 15 interviewers again verbally presented each card and women identified cards with stressors that they considered applicable to their typical routines excluding those that were not applicable from the remaining questions next interviewers asked women to sort the cards into three piles based on how frequently they encountered the problem always sometimes or rarely the groupings were recorded and the interviewer shuffled the cards for the next question finally participants were asked to sort cards based on perceived severity high medium or low after each exercise interviewers reviewed the rankings or piles and asked participants to describe their reasoning with openended questions interviewers took detailed notes of both the ranking and sorting outcomes as well as participant responses ranking and sorting results were entered into a database and openended questions were digitally recorded transcribed translated and deidentified data analysis for sanitation behaviors ranking data on stress and freedom were modeled using rankordered logistic regression by maximum likelihood specifically with the rologit command in stata 131 29 rankordered logistic regression is used to estimate the probability that an itemin our case a sanitation behaviorwould be ranked by a respondent as first along the characteristic of interest rankordered logistic regression accepts incomplete rankings making it amenable to data where participants can discard some items or as in our case exclude inapplicable items as long as we assume that omitted items are ranked lower along the trait of interest than all items that were retained unlike conditional logit models that only account for how often an item was ranked first among a set rankordered logistic regression takes into account all ranks assigned to an item therefore two items with equal numbers of first place rankings can be differentiated in the rankordered model based on how many second third etc rankings they received frequency and severity data regarding stressors arising during sanitation practice were interpreted as likerttype scale ratings we found that reporting and comparing percentages of high severity and always responses was sufficient to illustrate variations of concerns across groups ethical approval prior to the interviews all participants provided written consent for girls under 18 interviewers collected written assent from the participant and written consent from her parent participants were informed of their rights to terminate the interview at any time and to skip any questions or topics that they did not wish to discuss names and other identifiers collected during the interview were redacted during the transcription process and the original audio files destroyed ethical approval for this study was provided by the ethical review committee at aiph and the institutional review board at emory university results participant characteristics table 1 presents characteristics of the 60 study participants by geographic site women ranged in age from 14 to 45 years old the majority of the participants and all women in rural areas identified as hindu access to a private or public latrine was limited the majority of our participants did not have access to latrine facilities and were forced to practice open defecation latrine access was highest among participants in the urban population sanitation behaviors table 2 presents the percentage of women in each geographic region who selfreported engaging in each of the seven sanitationrelated behaviors of interest we assessed whether or not women engaged in these activities to ensure that women only responded to issues that were pertinent to them in the subsequent exercises these questions were not asked to compare habits of women in urban versus rural versus tribal areas women everywhere report defecation urination postdefecation cleaning and bathing as part of normal sanitation practice women in rural areas reported less carrying water for sanitation purposes since many use sites at or near open water sources or were more likely to walk to a pond or a river to complete their washing only 25 of women in the tribal site reported changing clothes after defecation a practice that women reported in previous qualitative interviews to be strongly linked to hindu beliefs about ritual cleanliness 15 stress table 3 shows results of the rankordered logistic regression analysis for stress and freedom indicating the probability of a specific behavior being ranked first we present the data in as raw a format as possible to encourage a more nuanced understanding of the responses than statistics such as modes and or measures of dispersion would supply menstruation was most likely to be ranked as the most stressful behavior in our total population followed by defecation and urination however the ranking of stress associated with these behaviors varied considerably according to geographic site for example menstruation was highly likely to be ranked as most stressful among rural and tribal women but carrying water was the most stressful aspect of sanitation practice in urban areas tribal women were about twice as likely to rank defecation as most stressful compared to urban and rural respondents stress rankings also varied by life stage for adolescents defecation was ranked as the highest stress followed by menstruation bathing and post defecation cleaning menstruation was most likely to be ranked as high stress among newly married and pregnant women carrying water was also among the most stressful activities among newly married women pregnant women and established adults freedom daily sanitation activities take women out of the domestic environment in order to access latrines fields for open defecation or communal water sources women face restrictions dictating when and how they may practice these activities such as when they leave the household where they go and whom they are allowed to go with table 3 presents the probability that a woman ranks a sanitationrelated activity as the one she can practice with the most freedom overall women had a high probability of ranking urination as the behavior with the most freedom a pattern consistent among all of our geographic and life course groups the two activities least likely to be ranked as having a high degree of freedom were changing clothes and menstruation we note some variation in freedom by geographic site and life stage group among rural women the activity most likely to be ranked as having the highest degree of freedom was changing clothes followed by urination postdefecation cleaning and bathing when comparing across life stages though urination is most likely to be ranked as most free by adolescents newly married and pregnant women established adults had a higher probability of ranking bathing as most free defecation was ranked with a relatively high degree of freedom for adolescents newly married and established adult women however this is the least likely to be ranked as most free among pregnant women indicating that pregnant women may face greater restrictions associated with this practice based on their physical needs and the social and cultural restrictions accompanying pregnancy fig 1 provides a visual representation of results combining data on the percentage of women who reported completing specific behaviors probability of a behavior being ranked as most stressful and the probability of a behavior being ranked as having the most freedom fig 2 depicts this same visualization by life stage and geographic region among the total population we note a clear and expected negative correlation between the probability that a behavior would be ranked as most stressful and as having the most freedom only changing clothes is an outlier from this general trend this trend is less pronounced when visualizations are developed for each geographic area and for each life stage group in particular the graph of rural responses shows a steep association linking high freedom activities with lower stress compared to more restricted activities like menstruation with a high degree of stress in the tribal site the relationship between stress and freedom was less clear however the relative association between activities does follow the general trend conversely among adult women the relationship applicability stress and freedom associated with sanitation activities the diameter of each circle is proportional to the percentage of women who indicated the activity was applicable to them the location of the center of the circle relative to the horizontal and vertical axes indicates the probability that the activity was rated most stressful and most free respectively doi101371journalpone0141883g002 between stress and freedom is slightly positive and activities less likely to be associated with freedom are more likely to be associated with greater stress sanitation stressors we asked women to indicate what stressors they faced during sanitation based on twenty previously identified problems that were highly salient to women in odisha 15 overall women most commonly indicated rain nightdarkness animals and health during illness as sanitation stressors with 87 or more of women indicating these were problems they faced in all sites women identified an average of 13 out of the 20 potential stressors as applicable to their sanitation practice table 4 summarizes the results of constrained pile sorting of stressors by frequency with which it is encountered and severity of the stressor frequency and severity overall the issues more likely than not to be considered applicable as always a concern and as stressors of high severity were rapeassault distance reputation and ghosts for the minority who considered it applicable lack of space was also predominantly considered a persistent and severe concern these stressors span multiple domains related to sanitationrelated psychosocial stress 15 including the built and social environments lack of space and distance stand out as especially prominent sanitation infrastructurerelated concerns compared to physical barriers rapesexual assault and reputation are distinguished from for example being scolded as particularly poignant constructs of the social environment that induce srps among the most concerning of stressors we also find an example from the domain of cultural beliefs namely encountering ghosts the types of stressors and the frequency and severity with which they were encountered ranged by geographic site and life stage group while the majority of women in all sites and life stage groups reported the majority of the 20 stressors as applicable the variation in describing those stressors as frequent or severe manifests the importance of understanding the context in which women encounter srps for example urban women identified physical barriers as more applicable to their sanitation behaviors than rural or tribal women and half of urban women rated physical barriers as a high severity concern rape and sexual assault was particularly salient in the urban group where 70 of women said it was a stressor among these urban women 86 were always concerned about it and 100 described it as a highly severe issue in comparison only 55 of rural and tribal women identified rapesexual assault as applicable and among these women it was not categorized as always a concern and 64 of women in both groups said it was highly severe being seen a construct of the social environment had roughly equal applicability across groups but happened infrequently among women in the tribal site and seldom considered severe males teasing or throwing stones was also similarly applicable across geographic sites but varied greatly from rural women indicating that even when applicable it was never a high severity stressor nor one that was always a problem tribal women agreed that males teasing or throwing stones was not always a problem but when it was it was severe the salience of specific stressors also changed by life stage rape was salient to a majority of women in all groups but in no group was it as often considered salient frequent and severe as it was among adolescents reputation was a concern shared almost equally by adolescents and newly married women with 80 in both groups considering it salient and 83 in both groups considering it high severity half of newly married women and 67 of adolescents viewed it as always a concern pregnant women were especially concerned with issues that they perceived to be detrimental to their pregnancies such as encountering ghostsa concern that was not as often salient frequent or high severity in other life course groups we note a general positive trend between the perceived severity and perceived frequencies of stressor issues that were commonly ranked as highly severe were also commonly ranked as issues they always encounter lack of space sexual assault and distance were likely to be ranked as both high frequency and high severity issues visualizing results also shows us exceptions to this relationship for example when applicable adolescents encountering physical barriers ranked them as something they always encounter however this was not likely to be ranked as a severe stressor likewise adult women who ranked ghosts as a stressor were not likely to rank them as a frequent stressor but they were often ranked as a high severity issue discussion using structured data collection methods for this research allowed us to explore the scope and dimensions of key sanitationrelated stressors in a more nuanced manner than a survey would afford and more systematic than exploratory qualitative research ranking sanitationrelated behaviors from most stressful to least stressful helped us to explore how stress manifests across sanitation activities women consistently ranked menstruation and carrying water as highly stressful activities contributing to srps water is an essential component of sanitation related behaviors in this setting and was used in postdefecation cleaning bathing and for menstrual hygiene management 15 in urban areas women usually rely on shared public water sources that may be intermittently available and the burden of collecting and carrying water to a site for defecation or urination was highly problematic despite the links between carrying water and other sanitation behaviors water and sanitation provision in india are often operationalized independently the delivery and provisioning of water may be coordinated by a states department of public health and engineering or by the state water board however different statelevel departments may implement sanitation programs in theory indias total sanitation campaign aimed to incentivize userand communitydriven demand for sanitation but the focus on infrastructure development has been criticized as a topdown governmentled approach 30 the swachh bharat mission the recently launched governmentled sanitation campaign in india has committed billions of dollars to improve sanitation coverage through infrastructure development user incentives and communitymobilization however efforts remain targeted on sanitation infrastructure at the householdlevel though the nonprofit and private sectors play a role in increasing water sanitation and hygiene services throughout the country our data show that sanitation behaviors rely heavily on water access suggesting the need for coordinated interventions among different levels of government and the public and private sector that respond to the social and physical needs of the users furthermore the majority of sanitation interventions focus on defecation and fecal management and often ignore other sanitation related behaviors like washing and menstrual hygiene in addition though the psychosocial implications of menstruation and menstrual management have been documented among adolescent girls 31 32 33 34 few studies have critically examined the psychological interpersonal and social repercussions among older populations our data highlight that stress related to menstrual management is particularly salient among newly married and pregnant women newly married women described that menstruation is highly stressful because they are new in their households and have to curtail their regular activities based on cultural traditions restricting sanitation behaviors they feel uncomfortable talking about menstruation with their husbands and inlaws and the physical symptoms associated with the diameter of the circle is proportional to the percentage of women who reported that the stressor was applicable to them the location of the midpoint of the circle on the horizontal and vertical axes reflects the proportion of those women who indicated that the item was a high severity stressor and high frequency stressor respectively only stressors that were highly applicable severe or frequent are included in each graph doi101371journalpone0141883g003 menstruation inhibit their normal activities similarly pregnant women described menstruation as highly stressful even though they were not currently experiencing monthly periods newly married and pregnant women living in their inlaws households face social restrictions surrounding menstruation and all sanitationrelated behaviors such as restricted water access and taboos related to sexual intercourse cooking or religious practices during their periods 3536 correspondingly menstruation was also the least likely to be associated with a high degree of freedom among these women strategies that women may have had as adolescents may need to be renewed upon marriage and relocation into a new household our results highlight the dimensionality of sanitationrelated of stressors we found that even stressors that occur less frequently may still be high severity issues and that the intensity of stressors vary by life stage and geographic location examining stress and food security a recent food and agriculture organization study found a relationship between severity and frequency discussing how more severe indicators of food security are less frequently noted than less severe items 37 in our study we similarly found that fewer women encountered some of the stressors that were most severe for example sexual assault was not commonly included as applicable but when included it was likely to be ranked as a high severity high frequency issue especially for adolescents and in urban areas violence that occurs due to inadequate access to water sanitation and hygiene facilities is of increasing concern in the water sanitation and hygiene community recently rape and sexual assault associated with sanitation have received more attention in indian media explicitly linking lack of sanitation facilities with violence rape and lack of safety for women 38 39 40 a review of literature examining genderbased violence and wash shows how sensitivity secrecy and the complexity of violence inhibits the collection of reliable data and the authors advocate for building an evidence base grounded in systematic ethical evaluation of wash related violence 41 our research identified violence and sexual assault as high severity stressors but further research is needed to quantify the scope of the problem and suggest interventions beyond the physical and social stressors associated with sanitation this study illustrated how fear of ghosts was also perceived to be highly severe especially among rural pregnant and adult women the high severity of this issue may be due local traditional beliefs linking miscarriage to encounters with ghosts though we were unable to find studies specific to odisha an ethnographic study by pauline mahar kolenda of sweepers in north india discusses a range of anxieties related to ghost and supernatural encounters including the attribution of miscarriages to malevolent female ghosts 42 this example highlights the usefulness of examining the stratification of stressors especially when culturally significant proscriptions impact sanitation behaviors understanding the dynamic sanitation behaviors stressors and the attributed level of severity is essential for informing practitioners about the context and implications of intervention identifying how stressors are related to location and life stage may help assign priorities in creating safe sanitation spaces for example for newly married women physical barriers were less likely to be ranked as highly severe than for women in other life stage groups women in our study occasionally mentioned special places near the home where newly married women could defecate and in some cases improvements to the home are used in negotiating a marriage in rural haryana india access to sanitation was used as bargaining power in a campaign called no toilet no bride minimizing social restrictions for newly married women during sanitation and improving standards for sanitation access 43 this example suggests that interventions focused on physical barriers are more greatly needed for adolescent pregnant and established women than for newly married women in advocating for a contextualized gender sensitive approach to sanitation our research findings inform future study of srps illustrating key differences across life stages and social settings additionally given the numerous ways women experience stress related to sanitation further study may illuminate factors that ameliorate stress using systematic data collection techniques helps to populate a range of factors and then explore them to identify relevance key priorities and more nuanced dimensions like stress severity and frequency women in different parts of india face a distinct constellation of stressors and their severity depending on physical surroundings life stage and access to sanitation facilities understanding the dynamics of how social geographies and life course stages shape womens sanitation experience may help to tailor sanitation needs given cultural and geographic diversity strengths and limitations the systematic data collection methods employed in this study helped us to explore sanitation related psychosocial stress using an interactive format and generating comparisons between women of different ages living in different geographic locations the results highlight some key areas that can help to inform future research on sanitation related to mental health however more research is needed to develop locally relevant psychometric scales we recruited five women per life stage group per site for 60 total participants allowing us to examine results in both social and geographic groupings however a larger sample size may afford more granularity in examining trends by life stage group and geographic site simultaneously it would also be valuable to explore the relationship between freedom and stress using a larger sample size additionally some of the sanitation behaviors and stressors are shaped by cultural practices and socially defined roles so the generalizability of some of our findings may be limited to lowresource settings of india conclusions factors contributing to srps differ by life stage and geographic site and the context of sanitation must be understood to inform successful sanitation interventions understanding the network of factors relationships and activities influencing mental health and feelings of distress gives us a more nuanced understanding of the ways women negotiate their sanitation environments further research measuring srps may help to significantly inform sanitation interventions signposting key areas for infrastructural development and behavior change messaging all relevant data are within the paper and its supporting information files

emerging evidence demonstrates how inadequate access to water and sanitation is linked to psychosocial stress especially among women forcing them to navigate social and physical barriers during their daily sanitation routines we examine sanitationrelated psychosocial stress srps across womens reproductive lives in three distinct geographic sites urban slums rural villages and rural tribal villages in odisha india we explored daily sanitation practices of adolescent newly married pregnant and established adult women n 60 and identified stressors encountered during sanitation responding to structured data collection methods women ranked seven sanitation activities defecation urination menstruation bathing postdefecation cleaning carrying water and changing clothes based on stress high to low and level of freedom associated with greatest freedom to having the most restrictions women then identified common stressors they encountered when practicing sanitation and sorted stressors in constrained piles based on frequency and severity of each issue the constellation of factors influencing srps varies by life stage and location overall sanitation behaviors that were most restricted ie menstruation were the most stressful women in different sites encountered different stressors and the level of perceived severity varied based on site and life stage understanding the influence of place and life stage on srps provides a nuanced understanding of sanitation and may help identify areas for intervention

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introduction the social economic and political impacts of noncommunicable diseases are now recognized to be some of the greatest challenges facing countries in their efforts to deliver on sustainable development goals and universal health coverage 1 whilst the public policy dialogue has focused on communicable diseases research into ncds has received little attention 2 3 relative to their available economic resources many of the middle east and north african countries have not historically achieved good health outcomes 4 the recent health systems reform series on health in the mena region provided evidence of the heterogeneous patterns of health outcomes across this region 5 despite poor outcomes in conflictimpacted countries such as syria iraq libya yemen and afghanistan over the last two decades child and adult mortality rates have declined across the mena region as a whole particularly in saudi arabia iran qatar the united arab emirates oman and turkey 67 8 the mena population most at risk of ncds ie those aged over 60 currently ranges from 08 in the uae to 106 in turkey 9 these percentages are expected to increase significantly by 2030 as a result of the demographic transition due to continuing improvements in life expectancy compounding this demographic effect is exposure to ncds risk factors such as tobacco obesity and hypertension which is highly prevalent across the mena region in bahrain egypt jordan kuwait saudi arabia and the united arab emirates adult obesity is becoming a major issue in both men and women 10 and almost 25 of the mena population suffers from hypertension 11 estimates from the global burden of disease study show that the highest prevalence of obesity among adults 20 years or older in 2015 was observed in qatar with 425 among males and 524 among females and in the younger population of children 219 years in kuwait with 221 among males and 192 among females whilst tobacco use is declining worldwide according to the world health organization global report on trends in tobacco smoking 20002025 the prevalence of tobacco smoking in the mena region is projected to increase between 2010 and 2025 12 there is also wide variation in the demographic patterns of cigarette smoking with prevalence among older men at 3050 in egypt jordan and bahrain compared to 715 in the uae and oman 13 moreover waterpipe tobacco smoking is increasing among the youth in the region cardiovascular disease cancer and diabetes represent up to one third of the current disease burden in the mena region the cardiovascular disease burden has remained relatively stable between 2000 and 2015 rising from 175 of all dalys to 189 the burden is twice that of cancer the burden of which has increased from 86 to 102 of all dalys in the same time period diabetes represented 43 of all dalys in 2015 up from 25 in 2000 despite the rising risk factor exposure and ncd mortality regional public health policy responses have been slow historical and future r d activity in ncd is foundationally dependent on the knowledge economy of these countries however in many places this is still lagging behind in the face of the significant public health threat from ncds and the drive to improve health systems research and address the knowledge gap in the mena region there is a need for evidencebased intersectoral measures for ncd prevention and care in the mena region and for an understanding of how to improve the ncd research capacity and capability across the region to achieve this it is important to understand from a public policy perspective how why and which particular ncd research domains have evolved for example how do different countries influence the ncd research agenda either through the volume of research they publish the citation impact of their articles or their commitment to particular research domains an empirical analysis of research outputs would also highlight gaps and provide direction as to which research areas should be prioritized to meet current and future challenges using a bibliometric approach we present a high resolution analysis of ncd research in ten key bell weather countries that reflect the diversity of the mena region between 1991 and 2018 to characterize its breadth and depth and how these have evolved over the course of nearly three decades this type of analysis is now used routinely in public policy analysis to study research domains 14 15 16 17 a bibliometric approach allows one to understand and characterise research in the region to provide an understanding of the research capacity to manage this burden relative to wealth and individual disease burden in addition it provides a focus for understanding areas for informing policy by providing insight into research prioritisation research impact and the extent of regional and international collaborations we therefore examine the growth in ncd research outputs over time the volume of research produced relative to the countries wealth population size and ncd disease burden in addition we assess the citation impact of each countrys ncd research as well as the impact of intraregional and international collaborations on the volume and quality of research outputs methods a number of different definitions for country composition of the mena region currently exist 18 with some including turkey our analysis of ncd research activity covers the 10 major researchactive countries in this region for the 28year period between 1991 and 2018 the selected countries are egypt iran jordan kuwait lebanon oman qatar saudi arabia turkey and the united arab emirates international standards organization digraph codes for each country are listed in table 1 we excluded countries that are considered politically unstable eg iraq yemen and syria and did not include smaller research producing countries such as bahrain libya palestine as they would not be informative for understanding overall ncd and workforce policy in the region we also wished to look at broad trends of countries within a specific researchpolitical nexus hence exclusion of both low output countries and specific countries in north africa that are not part of the intraregional research nexus in addition for each country we cover the three most prevalent ncds in the mena region cancer cardiovascular disease and diabetes research papers from the 10 selected countries were identified from the web of science in the selected ncds by means of three separate algorithms developed by gl in collaboration with experts in these ncd fields each of these three filters consisted of two parts a list of specialist journals for each ncd and a list of specific title words there were 185 specialist journals listed for cancer 115 for cardiovascular disease and 36 for diabetes and there were 323 title words or phrases used for cancer 125 for cardiovascular disease and 35 for diabetes of note the cardiovascular filter includes cerebrovascular accident each filter was independently applied to all papers identified from each of the 10 countries within the wos papers satisfying either criterion or both were selected for analysis each of the filters has undergone a process of calibration during the development phase to assess their precision and recall 19 the filters have been used previously in other analyses 142021 and the process of development of the cancer filter for example is listed 22 for the three ncd domains sensitivity and specificity rates were calculated as follow with sensitivities and specificities above 90 considered high • cardi p 095 r 090 • diabe p 090 r 098 • oncol p 095 r 098 a separate filter for biomedical research was developed and also applied to the wos 19 the rationale for this was to provide a baseline from which the relative increases in volume of research outputs in the three ncd domains can be considered it also provides the relevant context for understanding the commitment of each country across all biomedical research domains this was based not on title words but on words in the addresses of the papers that indicated the name of the department eg department of cardiology or the institution such as nih there were a total of 172 terms in this filter and it has been found to distinguish well between biomedical and nonbiomedical papers in multidisciplinary journals such as nature and science assessment of research output relative to gdp and disease burden an analysis was undertaken to determine whether the amount of biomedical research in each mena country in 201118 was commensurate with its overall wealth as measured by gross domestic product and also with its respective population size the research output in each of the three ncds was calculated as a proportion of total biomedical research output a comparison was also made with the relative burden of disease measured in disability adjusted lifeyears attributable to each ncd disability adjusted life years are the sum of years of potential life lost due to premature mortality and the years of productive life lost due to disability based on how bad particular problems are these were calculated as percentages of dalys attributable to all causes for each country in the years 1990 to 2015 23 it was therefore possible to compare for each country the proportion of research into each ncd domain relative to its total biomedical research output with the proportion of dalys attributable to each ncd this was calculated for two 10year time periods to assess what the changes in commitment had been relative to the changing disease burden contribution of basic compared with clinical research over time the research level of the papers was assessed for the papers in each domain from each country and for the two decades 19962005 and 200918 the mean research levels give an indication of the countries commitment to clinical research relative to basic science within that ncd it is based on the presence of selected clinical and basic science words in their titles groups of papers were assigned a value of rlp between 10 and 40 depending on whether their titles contained one or more of a list of clinical words eg diagnosis elderly basic words eg activation binding chromosome or both 24 impact of international collaboration on quantity and impact of research international collaboration was assessed by calculation of the proportion of biomedical research outputs within each of the mena countries that had foreign addresses between 2011 and 2018 for this purpose the numbers of each countrys papers with no other country present among the addresses were determined and then subtracted from the total output a further analysis revealed the extent of international biomedical research collaboration between the selected 10 mena countries and others in the mena region as well as with the top 10 biomedical researchactive countries globally the indicator used was the salton index this is defined as the ratio of the numbers of joint publications to the square root of the product of the two individual totals multiplied by 100 for the biomedical research papers the actual citation impact was calculated as the number of citations received by a paper in the five years beginning in the year of publication a fiveyear window was used as it represents a compromise between the need for immediacy and stability for the biomedical papers from 20012010 aci values were obtained from the wos for each of the ten countries and for each publication year because these scores varied from year to year particularly for the smaller countries threeyear running means were calculated so as to smooth out this variation results outputs of research papers in the three ncds between 19912018 495108 biomedical papers were found in 12341 journals for the 10 mena countries altogether in cancer there were 52911 papers in 4344 journals in cardiovascular disease there were 49234 papers in 4382 different journals and in diabetes there were 13298 papers in 2403 journals nearly all of the papers were in english but others were in 19 different languages led by turkish with 12 in 2015 17 of the diabetes papers 18 of the oncology papers and 21 of the cardiology papers were published in journals from eight of the selected mena countries the papers were primarily from turkey and iran saudi arabia and the uae contributed less than 4 of the mena total the four leading mena journals are all turkish archives of the turkish society of cardiology journal of clinical and analytical medicine anatolian journal of cardiology and turkish journal of thoracic and cardiovascular surgery the research outputs of the 10 mena countries in the three ncds for the years 19912018 are shown in s1 s2 and s3 figs for cancer cardiovascular research and diabetes respectively with few exceptions there is a trend of increasing outputs over time in all countries for all three ncds and turkeys output is consistently the highest iran has overtaken several other countries to occupy second place across all three ncds egypts output has also expanded quite quickly to overtake that of saudi arabia the correlation between country biomedical research outputs and wealth population and disease burden during the eight years 201118 the 10 mena countries published 328585 biomedical papers in 10855 different journals biomedical research activity was poorly correlated with the wealth of the 10 mena countries in 2014 but much better with their populations in both figs 1 and2 the spots for kuwait oman and the united arab emirates all lie below the regressionline and those for iran and turkey lie above the line the relationship between disease burden and research activity is complex with a heterogeneous picture across the 10 mena countries both within each ncd and between ncds with a few exceptions the mena countries do more research on cancer than the burden would appear to justify conversely cardiovascular disease and diabetes appear to be underresearched this dynamic is illustrated in figs 3 4 and 5 for the three ncds the arrows from blue squares to red squares show the changes in both disease burden and in research output one could expect that the countrylevel research outputs within each ncd would be approximately proportional to the relevant disease burden in which case the spots should all lie on or close to the diagonal fig 3 covers cancer research and shows that it is given significant research prioritisation relative to its disease burden in all the ten mena countries except for turkey in the last decade for several countries the commitment to cancer research as measured by research outputs is becoming greater jordan the united arab emirates qatar iran and lebanon all had their output approximately in balance with the burden in 19962005 but they did a lot more cancer research in 200918 despite the burden being little changed prioritisation relative to its health burden in all ten mena countries except for qatar where it clearly was highly prioritised with 22 of total biomedical research output in 19962005 however for most of the countries the red spots are closer to the diagonal line than the blue spots showing that both the amount of research has increased across the two decades kuwait or turkey and that the relative cardiovascular disease burden is going down except in egypt lebanon and saudi arabia fig 5 covers diabetes and shows that the burden of disease is increasing in all ten mena countries apart from the united arab emirates for which diabetes research has been a major research priority when compared with the other nine countries during the time period of analysis the increase in diabetesrelated disease burden is particularly marked in saudi arabia iran oman and turkey with respect to research outputs egypt iran jordan and qatar all had relatively low commitments to diabetes research in the 19962005 period however they have increased their outputs considerably in the recent decade as has kuwait reflecting its persistently high diabetes burden ncd research levels ncd research activity is mainly clinically oriented only egypt appeared to do rather more basic research than the other mena countries in the three ncds whilst cardiovascular and diabetes research outputs have become slightly more clinical on average cancerrelated output has become more basic compared to the previous decade as exemplified by the united arab emirates there has been a noticeable shift towards basic research for oncology in qatar over the two decades research outputs in all three ncd domains have become increasingly basic in saudi arabia citation impact of mena biomedical research outputs between 2001 and 2010 the mean fiveyear citation scores for biomedical research have been steadily increasing in all ten mena countries there have been marked rises in citation scores in qatar lebanon united arab emirates and oman turkey which has the largest biomedical research output in the middle east has only achieved a marginal increase in its citation scores over this time period and has the lowest citation scores overall fig 5 graph demonstrating relative commitment of each me country to diabetes research compared to its diabetes specific disease burden measured as a percentage of dalys attributable to international collaboration for the three ncd domains we obtained the numbers of internationally coauthored research papers in the three subject areas from each of the ten mena countries between 201618 there is substantial variation in the percentage of foreign involvement with greater proportional collaboration seen in those countries that have smaller output as exemplified by qatar united arab emirates oman and lebanon conversely it appears that those mena countries with larger outputs such as iran and turkey collaborate less internationally this is particularly marked for turkey with an average of only 15 foreign contribution across all three domains of ncd research fig 7 shows the relationship between international research collaboration in 200910 for the ten mena countries and the influence of their published biomedical research as measured by fiveyear citation counts in the wos the citation counts appear to be well correlated with the extent of international collaboration with those countries that have a larger proportion of their papers coauthored with other countries having higher mean citation counts both qatar and lebanon have higher citation scores than expected on the basis of the regression line we examined the amount of collaboration with countries outside the ten mena states between 201118 the salton index values for the 10 most biomedically researchactive countries are shown in table 2 the united states and united kingdom are the dominant research partners across the region followed by germany france is notable for its collaboration with lebanon and the united kingdom for its collaboration with qatar egypt collaborates extensively with the united states and germany saudia arabia appears to collaborate with a number of major research active countries including the us uk canada australia and india italy is noticeable for its collaboration with turkey which collaborates little with other international partners we investigated which mena countries the ten mena countries collaborated with in the eight years 201118 much of their international collaboration was with each other and table 3 shows the salton index for each of the 10 mena countries with a coauthor from one of the other nine both saudi arabia and egypt appear to be the dominant research collaborators across the mena region as well as contributing to each others research output they are also key collaborators for oman qatar and jordan turkey and iran which are the two leading research active countries in the area show little evidence of collaboration discussion the majority of the mena countries have shown a rapid improvement in their health status over the last three decades primarily through a reduction in mortality from communicable diseases however their approach to managing the everincreasing burden of ncds has largely focused on a curative model with a proposed expansion of health care resources and uptake of new technologies rather than prevention and health promotion services 25 it is imperative that there is capacity building to strengthen biomedical research in the mena region to address the rising tide of ncds by improving international collaboration supporting investment in research and training and improving the research environment 26 the increase in research activity in ncds across the mena region during the time period of analysis may signal both an increasing focus on ncds which reflects general global trends and greater investment in research in some countries for example in qatar there has been a substantial increase in research funding 100 million over 10 years which perhaps explains its recent rapid improvement in research outputs and citation impact 27 it has also sought to align its clinical and academic health development strategies through the creation of academic health centers and partnerships 28 however our analysis shows that some mena countries particularly oman qatar kuwait and the united arab emirates are still substantially underinvesting in biomedical research relative to their gdp there is also continued evidence of low political commitment in the region poor financial support for researchers as well as poor access to funding for ncd research despite some major potential sources 25 this is illustrated by the fact that 46 of the worlds financial resources are produced in the eastern mediterranean region member states yet the share of health research resources in the region is only 06 29 the recent unesco report estimated that the ratio of gross domestic expenditure on r d to gdp was very low in the region and has been on average 03 97 of which was provided by public resources the positive point observed in this report is the increase in r d investment from a few countries for example this ratio was 003 in tunisia in 1996 but had reached 1 by 2000 in countries such as iran and egypt there is a 5year plan to reach 3 and 1 respectively by 2012 among the wealthier nations qatar has had a plan to reach 28 in 2011 29 ncd priorities in the region in terms of investment on particular ncds we note the relatively greater investment on cancer research compared with diabetes or cardiovascular disease in most mena countries despite cardiovascular disease causing the greatest healthrelated burden in addition the gulf cooperative states countries face a continued rise in diabetes incidence yet our findings show that compared to their wealth there is relatively less research prioritisation on addressing the burden the research outputs across these three main ncds are becoming increasingly clinically focused across the last two decades this is in contrast to findings across europe which demonstrates that some ncd outputs are moving in the opposite direction towards more basic science research perhaps as a result of the rising costs of clinical trials 15 international collaboration one mechanism for raising the profile and citation impact of research is through international collaboration mena countries vary substantially in the level of intraregional and international collaboration our findings illustrate that internationallycoauthored publications within the region included researchers predominantly from the usa followed by the uk germany and france this is in keeping with other studies which have shown that approximately 45 of all multinational publications include a us author 22 we also demonstrate a strongly positive association between international collaboration and higher impact publications in the mena region irrespective of the volume of research output by individual countries this association has been demonstrated previously and supports the role of international collaboration in developing a countrys research influence and infrastructure 22 while international collaboration may be seen as a research strength these associations may mask more complex underlying mechanisms for example in countries such as iran and turkey which collaborate significantly less than other countries in the region but are amongst the largest producers of biomedical research there is greater investment in research and thus a more developed infrastructure as a result researchers in these countries may choose to publish their research in regional journals with a low impact internationally in order to more effectively reach local policymakers and effect change at a local level this mechanism may also explain in part the low citation impact in some countries with the highest number of outputs but it may also reflect an international bias in favor of western research there are other caveats with this type of analysis in particular that the notion of collaboration does not guarantee that this is a partnership of equals or will necessarily result in building research capacity and capability this is more likely to be the case if partnership involves merely the provision of local data or tissue samples for research to be done in addition as well as coauthorship collaboration may be achieved through sponsorship and funding which we have not specifically analyzed investment in training to build a sustainable and effective research infrastructure and tackle ncds across the mena region there is a pressing need to increase the cadre of national researchers and health workers 21 on average there are only 25 health workers per 100000 people in countries within the organisation for islamic cooperation this is only slightly higher than the critical threshold of 23 per 100000 needed to deliver basic health services and compares with 41 per 100000 in nonoic countries further information on the number of academic researchers would also help to inform policy but this is currently not available research seeking to understand the barriers to building research capacity particular around creating a skilled workforce remains limited and further investigation is required across the mena region a possible factor is that research training is generally not a focus of the education that health workers receive and the reality is that they are often overloaded with routine clinical work without either the basic skills or time for research 30 on a more general level these countries lack the depth and breadth of higher education systems to generate a sustainable knowledge economy in part this is due to their relatively recent entry into the knowledge economy however many countries in the region have started to invest in their education infrastructure 31 in addition there is increasing awareness especially amongst national governments that there is too much dependence on international staff especially in the fields of science and technology in order to nationalize the research labour force there has to be structural reform with the introduction of clearly defined policies that focus on education training transfer of knowledge into home grown ncd research 32 limitations of this study the present study has both strengths and limitations the analysis has been undertaken on an individual country basis and findings with respect to country outputs are potentially skewed depending on the size of the population and resources of individual countries in addition mena countries which conduct many collaborative multinational studies may appear to produce comparatively fewer research outputs on the basis of fractional counts compared to iran and turkey for instance we have used citation frequency as a proxy indicator for quality of research and dissemination of scientific findings however a true evaluation of the scientific quality of publications cannot be achieved without an independent and dedicated assessment of their merit furthermore citation frequency cannot determine whether a publication changes practice and improves population health 33 we also acknowledge that the proportion of published studies that are trials is another mechanism for understanding the rnd infrastructure of each country however this was not included within our analysis we have selected publications available in the wos for analysis and it is therefore likely that some research output in national language journals has not been included which could affect our results in addition as with any bibliometric evaluation it is not possible to guarantee inclusion of all relevant papers however we have allowed for the lack of precision and recall of the three filters by making corrections to the numbers of papers finally although we examined the outputs of 10 mena countries our analysis may not hold for the other countries within the region we selected bellweather countries with the highest volume of research outputs during the timeperiod of analysis the additional microanalysis of lower research output countries would not inform the wider discussion regarding workforce training and investment in the region for example after excluding iraq syria and yemen due to their political instabilitycurrent ongoing conflictthe next highest research producers are bahrain libya azerbaijan palestine afghanistan whichbetween 20092018 produced 4343 publications we also considered the research ecosystem to enable comparison and therefore did not include tunisia morocco and algeria which are geographically distinct north african countries whos regional research connections are distinct from the rest of the mena region conclusion the increase in research activity in ncds across the mena region during the time period of analysis may signal both an increasing focus on ncds which reflects general global trends and greater investment in research in some countries the analysis demonstrates heterogeneity in research outputs relative to country wealth population size as well as variation in prioritization of research into cancer cardiovascular disease and diabetes across mena countries with no clear correlation with disease burden mena countries in this evaluation vary greatly in the extent of their collaboration with other countries in the region and that of international partners particularly the us and uk a number of mena countries have exceptional levels of wealth which could with the right policy measures and public health strategies offer an unprecedented opportunity to build vital ncd research systems 34 this research is expected to support research capacity building in the region by highlighting countries that still do not sufficiently invest in rnd relative to their gdp by focusing research prioritization towards high burden ncds in the region and by demonstrating how research impact can be improved through international collaborations all relevant data are within the manuscript and its supporting information files supporting information s1

despite the rising risk factor exposure and noncommunicable disease ncd mortality across the middle east and the north african mena region public health policy responses have been slow and appear discordant with the social economic and political circumstances in each country good health policy and outcomes are intimately linked to a researchactive culture particularly in ncd in this study we present the results of a comprehensive analysis of ncd research with particular a focus on cancer diabetes and cardiovascular disease in 10 key countries that represent a spectrum across mena between 1991 and 2018the study uses a well validated bibliometric approach to undertake a quantitative analysis of research output in the ten leading countries in biomedical research in the mena region on the basis of articles and reviews in the web of science database we used filters for each of the three ncds and biomedical research to identify relevant papers in the wos the countries selected for the analyses were based on the volume of research outputs during the period of analysis and stability included egypt

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on march 11 2020 the world health organization declared the covid19 outbreak a global pandemic as of february 2022 there have been about 430 million cases of covid19 worldwide including about 6 million deaths of this number over 78 million cases have contracted the virus in the usa with over 926 thousand deaths preventative behaviors such as regular hand washing maskwearing social distancing partial or total lockdowns and stayathome orders were implemented worldwide these preventative and seclusive measures have been linked with irritability anxiety fear sadness anger and boredom especially among college students in 2020 when the covid19 pandemic started the usa was home to 1075496 international students college students have been impacted by the pandemic in different areas including mental health issues such as anxiety depression loneliness anger fear and a negative impact on their education as well the covid19 pandemic changed the educational system as schools worldwide were forced to cancel inperson classes to help prevent the spread of the virus to students teachers and staff and the community at large in the usa academic institutions transition to online learning from midmarch 2020 until the fall semester of 2021 while there has been a slow return to facetoface learning many universities and colleges have expanded their online courses to provide virtual learning in addition traveling due to the pandemic continues to be a challenge for international students due to covid19 testing requirements and quarantine mandates and the potential for their study visas to be suspended if they return to their home countries for lengthy periods among the student population international students have been harshly impacted by the covid19 pandemic academically socially and economically due to their immigration status americans received financial support in the form of emergency funds covidreliefs stimulus checks and financial relief programs to relieve the economic burden on americans during the pandemic however because international students are not considered permanent residents or american citizens they were exempted from receiving financial support yet they faced increased vulnerability because they did not have familial and emotional support as a result most international students relied on their host institutions for emotional and financial support several studies show that before the pandemic international students especially those from lowincome countries had been experiencing stressors due to geographical locations and dealing with financial burdens from living abroad given these existing vulnerabilities school and business shutdowns during the pandemic exacerbated international students social and psychological stress and affected their academic performance and sense of selfworth studies found that american college students delayed their graduation dates withdrew from classes lost their internship opportunities and changed academic plans during the pandemic approximately 24 of undergraduates at a mediumsize university either delayed graduation or withdrew from classes these outcomes align with tinto s theory on student departure which argues that students are at risk of dropping out when they experience three major determinants academic difficulties the inability of individuals to meet their educational and occupational goals and their failure to become or remain incorporated in the intellectual and social life of the institution according to tinto for students to thrive and remain in school they need a balance of academic performance facultystaff interactions extracurricular activities and peergroup interactions in the study we will use the theory of student departure to explore how the covid19 pandemic disrupted international students livelihood resulting in academic difficulties loss of scholarships or assistantships internship placements loss of personal interaction and incorporation with their host academic institutions all of which negatively affected their socioeconomic wellbeing and academic performance the studys overarching goal is to explore the academic experiences of african international students during the covid19 pandemic and highlight relevant lessons for future crisis response given the number of international students attending american universities and colleges insights from the study can enhance our understanding of international students needs during crises at three levels the individual institutional and community at the individual level findings could suggest potential opportunities for support during the public health crisis at the institutional and community levels findings may inform practitioners on how universities and communities can partner to reduce the vulnerabilities of international students findings can also inform the design of internationalstudent friendly national policies methods research design and setting this paper uses a qualitative research design to explore the academic experiences of african international students during the covid19 pandemic indepth interviews were conducted by four research team members using a semistructured interview guide the study design was chosen to understand the lived experiences of international college students a population rarely studied during a disaster the chosen population represented graduate students enrolled in a research institution at the onset of the covid19 pandemic we uncovered many unspoken realities of international students academic life during the pandemic by applying qualitative inquiry the study took place at a large research institution in the midwest there were 1931 and 1455 international students registered at the university during the 20192020 and 20202021 academic years respectively the enrollment rate continued to drop mainly because of the covid19 pandemic and reached 1436 during the 20212022 academic year during the study period international students representing african countries during the pandemic were nigeria and ghana interviews were conducted by zoom during the pandemic between march and june 2021 research team members of the research team were international students from african countries racially similar but diverse in their gender identifications and student classification these individuals approached this study with scholarly and personal interests in identity and the meaning and significance of international students in terms of their roles in this study the first author a phd level behavioral scientist conducted most of the individual interviews while the second third and fourth authors advanced doctoral masters level students at the time worked directly with the first author in conducting interviews analyzing transcripts and generating themes the last two authors hold doctoral degrees in public health one of the authors guided the research design data collection and analysis both senior authors served as independent auditors the independent auditors role was to 1 guarantee that multiple perspectives of the data were honored and discussed and 2 help ensure that analysts assumptions expectations and biases did not unduly influence the findings participant recruitment using a mix of purposive and snowball sampling twentyfour african international students expressed interest in participating in the study the research team contacted their international student networks and student groups to recruit participants such as the african graduate student professional group and the university students international office the inclusion criteria included being an african international student currently enrolled in a graduate program 18 years and older and willing to be audio recorded procedures the institutional review board approved the study and related activities at the corresponding authors institution a semistructured interview guide was used to obtain detailed descriptions of academic life during the pandemic the interview questions were developed in three stages first the research team explored existing literature on international students wellbeing to familiarize themselves with international students academic experiences second data on the impacts of the pandemic on college students were examined and finally a consensus was reached on the interview questions the interview questions included how has the covid19 pandemic affected you academically and how has covid19 affected your career goals plans or timelines before the start of each interview participants were oriented about the aim of the study confidentiality and data management practices all participants gave their consent to participate in the study the interviews were audiorecorded via zoom the interviews lasted approximately 45 min all interviews were transcribed verbatim by four members of the research team twentyfour african international students were recruited however 15 african international students participated in the study most of the participants were phd students and the remaining were masterslevel graduate students nine students expressed interest in the study but did not participate due to scheduling conflicts analysis thematic analysis was used to identify themes and patterns and classify segments of the data under each category the research team reviewed the first three transcripts and developed a coding scheme during the process members of the research team examined relationships among the initial codes laid out the potential parent child and grandchild codes discussed and resolved all coding conflicts following the development of the coding scheme four of the authors shared and independently coded the rest of the transcripts using nvivo12 qualitative analysis software the research team held continuous meetings and virtual engagements to review define and code the themes and to finalize the analysis and interpretation to avoid the risk of overgeneralization in the thematic analysis attention was focused on producing thorough descriptions and detailed information on each theme more thorough immersion in the data also helped the research team to develop a good understanding of participants experiences and make meaning of the themes reflexivity and positionality were adopted throughout the research process to minimize the risk of personal beliefs experiences and positions that could affect the research findings and conclusions as a research team identified as international students with african origins they were aware of the potential bias in data interpretation hence the research team remained careful to reduce the impact of their experience preconceptions and interests by applying greater sensitivity to the participants opinions by presenting thick descriptions and direct quotes for example using multiple researchers during the data collection and analysis provided various perspectives that were discussed and agreed upon before final coding throughout this process the research team members were able to critically selfreflect on the lived experiences of african international graduate students living in the midwest usa and how that may have influenced the interpretation of findings findings there were 15 participants five females and ten males who participated in the study almost half of the participants represented early adulthood all participants selfidentified as black and most of the students were nigerians most participants lived in america for two to five years as phd students and relied on graduate assistantship as their primary source of income most of the participants were on f1 visas living offcampus in the four major themes from the thematic analysis were challenges with pivoting to online learning diminished academic performance disruption of academic timelines and stolen and missed opportunities theme 1 pivoting to online learning to limit exposure and the spread of covid19 on campus us colleges and universities moved from inperson classes to online while the rationale and benefits of this decision were obvious there were many unintended consequences on the part of african international students ranging from unmet individual preferences to difficult or unsupportive learning contexts learning format context and productivitya gift and a curse students select learning formats based on their abilities and preferences with some preferring more interactive formats than seclusive as a result of campus closure students had to do academic work from home which represented a considerable change in their daytoday living most students found the pandemic to be a curse as they experienced difficulties in getting academic work done at home one participant expressed how her life was impacted by the sudden pivoting to online when she preferred inperson lectures so it has been quite difficult for me personally on a personal level i prefer to be in class because of my attention span virtual classes are also a problem for me because it is quite difficult for me to sit down in front of the computer for long hours similarly another male doctoral student discussed how pivoting to online learning was disruptive creating enormous challenges for him to complete his research due to the mandatory stayathome orders i guess it covid19 also kind of affected my research because i was trying to get some articles out usually i like going to the office as a routine just to write and come back home because staying home writing can be a problem working from home presents challenges related to workspace technology internet availability and familial responsibilities for international students working from home create challenges as they may be tempted to engage in family discussions during study hours this challenge is common because of time zone differences with their home countries similarly another ghanaian doctoral student stated that phone calls from family members were a significant source of distraction i have been turning in work late sometimes about only one hour or 30 min before the deadline because i have to talk on the phone and it is mostly helping other people with situations a nigerian student referring to the boredom that resulted from the shelterinplace mandate remarked sometimes i just get tired of being at home while a ghanaian female doctoral student experienced difficulties because of her childcare roles interfering with her coursework she expressed her challenges working on her dissertation while balancing childcare duties i just completed my comprehensive exams during the lockdown i was done with all my classes and i was doing my dissertation i did all my defense and i did my comprehensive exam defense on zoom i could not do much during the day because my son was also homeschooling online and i have to monitor him every now and then he needed help with things so i could not work during the day at night when everyone else sleeps i get to work it kind of slowed me down switching from campus to a homelearning environment impacted student productivity most graduate students described how their inability to access workspaces on campus made it difficult to complete their assignments or research for example a masterlevel nigerian female student stated that my productivity was low and my productivity dropped significantly at some point similarly a female cameroonian doctoral student described her experiences with online learning and how it reduced her productivity the fact that i had to stay online zooming for about two and a half hours and more every day was a huge stress for me so sometimes apart from the online class i still have to read articles online looking at the computer and all and that brought with it a lot of mental stress for me and at a point i felt like i was not very productive a female nigerian doctoral student expressed similar concerns and detailed her challenges with productivity during stayathome orders my area of study which was library was kind of closed and i had my routine already before the pandemic eventually i was not really motivated to work from home even though i really wanted to be productive but it has been a little bit more difficult for me to produce anything academically that is for sure however some other students found the pandemic to be a gift for such students the transition to virtual learning provided added familial benefits such as the flexibility to learn from home while fulfilling other familial duties a masterlevel female student from nigeria who is the primary caregiver of her two schoolaged children stated initially it was good somehow i think it has been good i can always attend classes online i appreciate the fact that as a mom i can easily join classes even when i am late it has really helped my 8 am classes i can listen and participate more the fact that i do not have to skip classes or overly stress myself to go to class in person i prefer the online option asynchronous courses allowed students to set their schedules to engage in course content and provided the opportunity for them to take care of their familial responsibilities during the pandemic further students who were supported with the resources they needed to sustain productivity tended to be more productive a masterlevel male nigerian student studying computer science was able to use his work laptop at home he stated how pleased he was with his productivity during the pandemic it has been very good for me i have been more productive than ever i mean i wake up in the morning i can do some work any time i do not have to worry about the time being too early lack of social interactions social interaction is a powerful vehicle in learning and can aid individuals with organizing thoughts and filling gaps in their reasoning the participants missed the social interaction aspect of learning and thus shaping the participants academic experience during the pandemic a male ivorian doctoral student described difficulties in reaching out for assistance during the pandemic unlike prepandemic era when it was easy to walk into offices i have had to do a lot of that recently which i just do not like so many times some things i am supposed to do stall because i have to psych myself to write that email or write several emails to several people some of them could be very long i hate that part of the pandemic because you cannot walk into the office another nigerian male doctoral student reported difficulties in collaborating with other students online and cited an instance when he had a terrible experience with a group project my academics was affected with respect to collaborations i had difficulties with projects because you are in a virtual class and you dont know your classmates and you are asked to form groups to work on projects……for research ive had to adapt to communicating with people online as compared to moving around to meet someone in the lab when im stuck now i have to send emails or send messages on the chat and wait till whenever they respond so sometimes getting feedback during research has been slowed down other participants expressed disappointment in having to go through academic work alone for them the human interaction with professors and other students was an integral part of the learning process without which the learning experience was not as fulfilling as they had hoped i missed that inperson interaction with people also i feel the professors are not able to gauge when you are not really doing well it takes people away and you may not really know how well they are doing i just miss being in class i guess i have been missing a lot i miss class and i miss interacting with other students theme 2 diminished academic performance the study participants reported diminished academic performance and outcomes much of this experience was linked with struggles to keep up with schoolwork as the pandemic progressed mainly because the pivot to online learning which was thought to be shortterm turned out to be prolonged the extended period under the pandemic exacerbated the challenges international students were dealing with and these struggles manifested in students academic performance a female nigerian doctoral student explained i must say that there has been a change in terms of my preparedness since covd i have been studying less and having difficulties getting assignments done on time overall i have not been learning rather i have just been trying to keep up with schoolwork another female ghanian doctoral student who had similar experiences and needed extension for some of her papers narrated i have called for an extension when my sons school called me to pick him up due to another child being infected with the virus i also had to deal with the death of a loved one during that time though covid19 may not have been a direct cause they all piece together or played a role she believed that the pandemic indirectly affected her academics due to the added commitments and emotions associated with events during the outbreak such as childcare bereavement and emotions lack of motivation was also cited as a common challenge associated with schoolwork during the pandemic most students reported significantly limited academic productivity due to diminishing motivation and procrastination when the covid19 first started you tend to postpone procrastinate a lot so you lose sight of being in an academic environment because being at home like all day long makes you feel like well i have time you know so i was less motivated and less organized another male ghanian doctoral student elaborated i have been procrastinating a lot and i am in a tight corner my final project is going to be due soon and i am still with another paper that i need to write it is hard to just sit down manage my time and get as much done just doing 30 minutes of my work sometimes is a big accomplishment procrastination has been a big issue for me theme 3 disruption of academic timelines disruptions from the covid19 pandemic response influenced some aspects of progression and timelines for some participants especially those pursuing doctoral programs while academic milestones such as presentations publications internships and comprehensive exams were difficult to achieve given diminished productivity research activities requiring humanlaboratory interactions also stalled a male nigerian doctoral student detailed his frustration with disrupted research activities and how that affected his academic progression before the pandemic my plan was to graduate last year but the data analysis publication and writing got pushed back we could not have access to the lab and months were lost so i lost about eight months and i could not graduate at the expected time another male ivorian doctoral student explains how his research activities had slowed down due to communication challenges created by covid19related shutdowns you know when you are stuck on something you just move to the person sitting down in the lab but now you have to send emails or send messages on the chat and wait till whenever they respond so sometimes you are not getting any feedback which slowed my research echoing the same feelings another male nigerian phd student lamented over lost time so instead of four years its looking like its going to four and a half now or five years for international students staying on track with their studies is critical as their stay in the usa is determined by various external factors such as the type of visa sponsor requirements and their ability to secure employment postgraduation theme 4 stolen and missed opportunities while participants found the courage to adapt to the changes in academic routine they were discouraged by the pandemics influence on networking and career advancement opportunities an essential aspect of the international student experience in the usa due to social distancing regulations conferences and college events were canceled or pivoted to virtual inperson conference participation provides opportunities for students to connect with other students and faculty from various institutions and serves as a platform for sharing and receiving feedback on research projects a female nigerian doctoral student described her disappointment as follows i had submitted an abstract to a university in china and so we were waiting to go for the conference you know so i was going to travel to china for the presentation but the conference was canceled another participant with similar regrets for settling for a virtual event said it does affect my conference travel plans most of my conferences i had to do virtually during the pandemic internship opportunities were limited as many organizations had to shut down or make modifications to offer virtual internships unsurprisingly participants lamented missing internship opportunities and for some this had farreaching implications on their academic timelines and student visa status a male nigerian phd student noted i did not have many options for internships because many companies canceled their internship programs there were one or two companies i was hopeful for i did not just hear anything from them anymore so i had to postpone my internship plans to this year i have actually secured an internship and after discussing with my advisor it is more like okay it might lead to like one extra year you know because the covid19 pandemic created shortages of internship opportunities screening for the few available internships became extremely competitive as employers preferred usa citizens or green card holders over international students on other visas as stated by one participant you know because most jobs are now asking for either a citizenship or a green card holder so it makes it really tough discussion this exploratory study examined the academic experiences of international students during the covid19 pandemic the main findings highlight the range of academic vulnerability among african international students during the pandemic pivoting to online learning and its associated disruptions exposed an already vulnerable population to more challenges amendments to academic timelines reduced academic productivity and the inability to participate in practical training opportunities such as internships and conference presentations while higher education was no exception to the disruptive effects of the covid19 pandemic international students in usa universities may have been hit the hardest mainly because of a lack of institutional support for a population that has many other disaster risk factors associated with being immigrant students such as lack of native social network inability to travel employment restrictive visasinability to work offcampus lack of access to recreational resources outside campus and poor home access to wifi because campus closures and the transition to exclusive online learning were abrupt many college students struggled to adapt to the new way of learning the study participants mentioned struggles in keeping up with academic work due to a lack of motivation and limited access to help from tutors and fellow students in the absence of human interaction this finding supports the emerging literature on covid19 experiences of college students in a study conducted among 257 college students in a midsized university in the northeast usa interpersonal disengagement and struggles with motivation were significant issues reported by the participants during the covid19 pandemic in the same vein participants reported difficulties participating in and completing online group projects due to virtual communication challenges associated with using email groupme zoom and other online communication channels that lack interpersonal engagement this supports findings from an indonesian study where 301 1 3 covid19 and higher education a qualitative study on academic… dentistry students asked to evaluate their experiences with online versus inperson classes reported a preference for inperson over online learning amir et al found that most students disliked online classes and 60 thought communication was more difficult with online learning and resulted in less learning satisfaction another study among ghanaian students revealed similar attitudes towards online learning our findings also resonate with tintos hypothesis that perceived academic difficulties could endanger student retention in higher education in addition to communication challenges participants in our study further identified the inability to separate schoolwork from their at home activities as a recipe for exhaustion and fatigue that contributed to decreased academic productivity learning from home meant that student homes became classes and study rooms this study supports meeter et al findings that students had challenges with academic structure and planning because it was hard to separate work and leisure time further students who relied on oncampus spaces like offices and libraries were more significantly affected because they had to quickly make drastic changes to their home routines the lack of change in the environment created a monotonous routine of long screen and computer time resulting in a lack of motivation for intellectual creativity and productivity on a peculiar note participants highlighted how existing vulnerabilities associated with limited social networks within their communities and with family members in their own countries shaped their academic experiences during the pandemic similar research found that female students experienced more vulnerabilities due to african gender roles that place the responsibilities of cooking cleaning and childcare on women insights gleaned from our study suggest that female students were burdened with these extra responsibilities thus international female students with research projects or teaching assistant positions had to extensively stretch their capabilities to meet home demands although some participants were able to turn this change into opportunities and a few reported minimal challenges with the transition based on the support from their school departments the lifestyle change still took some time to adapt to especially in the absence of familial support the study participants also reported delays in academic timelines and milestones this was primarily due to the inability to conduct research work during the pandemic or challenges in coping with the drastic changes in academic demands studies among college students in the us found that delayed graduation dates withdrawal from classes and changes in academic plans occurred during the covid19 pandemic approximately 24 of undergraduates at the arizona state university had either delayed graduation or withdrawn from classes by the end of the spring 2020 semester another study among college graduate and undergraduate students in the appalachia region reported reduced productivity and missed academic milestones affecting graduation timelines the distribution of this experience was also markedly disproportionate with lowerincome students being affected the most international students have minimal financial opportunities given visa employment restrictions and exclusion from federal covid19 financial support while covid19 prevention policies during the pandemic may have intensified the distribution of these academic experiences researchers fear that the implications of these events could impact international student retention as predicted by tinto as with many college students in the usa the participants expressed disappointment regarding missed opportunities for internships and networking during the pandemic while more research is needed to quantify the density of this problem among international students literature among usa undergraduates indicates that 13 of the population reporting loss of internship positions or job offers rescinded during this time with networking being a significant part of the international student academic and cultural experience in the usa canceling conferences and other academic networking platforms represents tremendous lost opportunities some of our study participants had difficulties securing internship positions due to the pandemic and because this was a major milestone in some academic programs the resulting delayed graduation timeline is palpable hagedorn et al had similar findings when students from their study reportedly missed internship positions required for graduation due to the pandemic although the experience is like that of other students in the usa participants from this study specifically expressed concerns about being less likely to secure an internship position during the pandemic due to the competition for limited internship spots and the fact that some positions specifically exclude international student applicants in their eligibility criteria the covid19 pandemic influenced the participants academic life directly via the shift to online learning and indirectly through disruptions in career advancement and networking opportunities as international students their experiences were worsened by other social and regulatory barriers associated with studying in a foreign country therefore more attention needs to be focused on international students as vulnerable populations in higher education implications for practice insights from this study revealed a need for institutional support for international students during pandemics the onset of the covid19 pandemic the resultant campus closures and the transition to online learning highlighted pandemicrelated vulnerabilities among african international students these vulnerabilities call for institutional support for international students during crises to ensure their academic success and for the usa to continue to enjoy the economic social and cultural benefits international students bring to the economy in line with tintos theory there is a need to minimize academic challenges international students experience support social integration and provide adequate institutional support during the pandemic to create diverse and inclusive learning environments in which all students feel supported to do their best universities can establish studentserving disaster preparedness committees that could relate to and ensure that the needs of international students are met the federal government can also formulate immigrant visa policies that allow flexibility for international students to secure employment outside their universities during crises such as covid19 the study findings also suggest a need for quantitative research focused on the experiences of international students during the pandemic to figure out the density and possible mitigation opportunities for the challenges faced by these vulnerable groups of students limitations due to the qualitative nature of our study and the limited sample size our findings may not be generalizable to other international students additionally the study participants constituted students who have been living in the usa for more than two years thus their experiences could differ from newly enrolled international students who are likely to have even weaker support systems while struggling with cultural adaptation findings should be interpreted with caution because of the lack of gender diversity among the participants the sample consisted of cisgender participants and the ratio included more male students than female students future studies should include the experiences of more african international female students and students who selfidentify as transgender or nonbinary gender including multiple sexual identities would have enriched the study findings as these populations remain understudied we strongly believe that this study contributes to the emerging knowledge on the academic challenges faced by african international students during the ongoing covid19 pandemic the research team made every effort to maintain rigor and trustworthiness by applying principles of immersion thoroughness and reflexivity future studies should include a more diverse and representative sample of african international students by educational levels gender and sponsorship type future studies should also explore the role of demographics and culture in shaping the experiences of international students conflict of interest the authors declare no conflict of interest publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations springer nature or its licensor holds exclusive rights to this article under a publishing agreement with the author or other rightsholder author selfarchiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law

covid19 pandemic has harshly impacted university students since the outbreak was declared in march 2020 a population impacted the most was international college students due to limited social networks restrictive employment opportunities and travel limitations despite the increased vulnerability there has been limited research on the experiences of africanborn international students during the pandemic using an exploratory qualitative design this study interviewed 15 africanborn international students to understand their experiences during the pandemic thematic analysis revealed that the covid19 pandemic influenced participants academic life directly via an abrupt shift to online learning and indirectly through disruptions in an academic work routine opportunities for networking and career advancement resulting in lower academic performance and productivity these experiences were worsened by other social and regulatory barriers associated with their nonimmigrant status the study findings suggest an increased need for institutional and community support for international students as vulnerable populations during a crisis to promote sustained academic success

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introduction the structure of a social network is fundamentally related to the interests of its members people assort spontaneously based on the topics that are relevant to them forming social groups that revolve around different subjects this tendency has been observed with quantitative studies in several online social media in the past researchers have explored the relationship between information diffusion and network structure focusing on the structural and dynamical properties of specific topical communities such as groups supporting political parties or discussion groups about rumors hoaxes and conspiracy theories online social media are also favorable ecosystems for the formation of topical communities centered on matters that are not commonly taken up by the general public because of the embarrassment discomfort or shock they may cause those are communities that depict or discuss what are usually referred to as deviant behaviors conducts that are commonly considered inappropriate because they are somehow violative of societys norms or moral standards pornography consumption drug use excessive drinking eating disorders or any selfharming or addictive practice are all examples of deviant behaviors many of them are represented to different extents on social media however since all these topics touch upon different societal taboos the commonsense assumption is that they are embodied either in niche isolated social groups or in communities that might be quite numerous but whose activity runs separately from the mainstream social media life in line with this belief research has mostly considered those groups in isolation focusing predominantly on the patterns of communications among community members or from a sociological perspective on the motivations to that make people join such groups in reality people who are involved in deviant practices are not segregated outcasts but are part of the fabric of the global society as such they can be members of multiple communities and interact with very diverse sets of people possibly exposing their deviant behavior to the public in this work we aim to go beyond previous studies that looked at deviant groups in isolation by observing them in context in particular we want to shed light on three matters that are relevant to both network science and social sciences i how much deviant groups are structurally secluded from the rest of the social network and what are the characteristics of their subgroups who build ties with the external world ii the extent to which content produced by a deviant community spreads and is accessed by people outside its boundaries and iii what is the demographic composition of producers and consumers of deviant content and what is the potential risk that young boys and girls are exposed to it in this initial study we undertake to answer those questions focusing on the behavior of adult content consumption public depiction of pornographic material is considered inappropriate in most cultures yet the number of consumers is strikingly high despite that we are not aware of any study about the interface between adult content communities and the rest of the social network we study this phenomenon on a large dataset from tumblr considering big samples of the follow and reblog networks for a total of more than 130 million nodes and almost 7 billion directed dyadic interactions to spot the community that generated adult content we also recur to a large sample of 146 million queries from a 7month query log from a very popular search engine out of which we build an extensive dictionary of terms related to adult content that we make publicly available results show that • the deviant network is a tightly connected community structured in subgroups but it is linked with the rest of the network with a very high number of ties • the vastest amount of information originating in the deviant network is produced from a very small core of nodes but spreads widely across the whole social graph potentially reaching a large audience of people who might see that type of content unwillingly although the consumption of deviant content remains a minority behavior the average local perception of users is that neighboring nodes reblog more deviant content than they do • there are clear differences in the age and gender distributions between producers and consumers of adult content the differences we found are compatible with previous literature on adult material consumption producers are older and more predominantly male and age greatly affects the consumption habit strengthening it in males and weakening it in females related work groups in online social media computer science research has dealt extensively with the problem of classification of groups along structural temporal behavioral and topical dimensions the relationship between group connectivity and shape of information cascades has also been explored revealing an intertwinement between community boundaries and cascade reach that is particularly tight in communities built upon a common theme shared by all of their members the degree of intercommunity interaction has been analyzed mostly in the context of heavily polarized networks the most classical example being online discussions between two opposing political views these studies explored methods to quantify segregation but mainly focus on networks formed by two main divergent clusters deviant communities deviant networks have been analyzed mostly in isolation studies about the depiction of drug and alcohol use in social media adopted mainly the content perspective researchers aimed at identifying the elements that boost content popularity investigated the effect of gender on engagement and studied the perceptions that deviant content arises in the young public research has been conducted around anorexiacentered online communities also on tumblr investigating a wide range of aspects including the construction and management of member identities the processes of social recognition the emergence of group norms and the use of linguistic style markers similar studies have been published over the years on communities of selfinjurers and negativeenabling support groups in which members encourage negative or harmful behaviors fewer studies touch upon networkrelated aspects one notable example is the work by gareth et al that provides an overview of behavioral aspects of users in the pornhub social network with particular focus on the role of sexuality and gender more loosely related are studies on the socalled dark networks mostly motivated by the need of finding effective methods to disrupt criminal or terroristic organizations the study by christakis et al about the communication network between smokers and nonsmokers is one of the few quantitative studies that addresses the interaction between the social network and one of its subgroups but it strongly focuses on the phenomenon of contagion adult content consumption in the context of internet pornography consumption computer science literature studied the categorization of content and frequency of use a wider corpus of research has been produced by social and behavioral scientists by means of surveys administered to relatively small groups special attention has been given to the relationship between age or gender and the exposure to internet porn with particular interest to the age band of young teens numbers vary substantially between studies but clearly men are more exposed than women with men exposed more frequently and women more often involuntarily it is estimated that young teens that are often exposed accidentally and are also exposed to violent or degrading pornography researchers have also pointed out the potential harm that adult material consumption through internet can cause including addiction and increased chance of adopting aggressive behavior exposition also correlates with drug use and with lack of egalitarian attitude towards the other sex although delving into the potential harm of pornography is far beyond the scope of our work this inherent risks provide an additional motivation to focus on this particular type of deviant community deviant graph extraction this study uses data collected from tumblr a popular microblogging platform and social networking website the dynamics of the tumblr community are based mostly on three possible actions users can post new entries on their blogs usually containing multimedia content repost on their blogs any post previously published by others and follow other users to receive updates from their blogs in a streamlike fashion users might own multiple blogs but for the purpose of this study we consider blogs as users and we will use the two terms interchangeably we consider as deviant nodes those users who post content about a given deviant topic to identify deviant nodes we resort to data from search logs as shown in other studies if a deviant query hits a tumblr blog url then the blog is a candidate deviant node in our analysis we use a sevenmonth long query log of a major search engine from which we collected a random sample of 146m query log entries whose clicked url belongs to the tumblrcom domain we limit our study to queries that were submitted from the united states after a simple query normalization process involving lowercasing and the removal of numbers additional spaces and of the word tumblr with its most common misspellings we obtained about 26m unique queries that hit a total of 27m unique tumblr blogs as expected the distribution of number of queries hitting a blog is very skewed with most popular blogs being reached by hundreds of thousands of clicks originating from search queries in the remainder of this work we focus on adult content this being a very common deviant topic on the web the same kind of analysis could be conducted on any other deviant topic to maximize the accuracy and coverage of the set of discovered deviant nodes we devise an iterative semisupervised deviant graph extraction procedure given a query log q and a set k i of deviant keywords we define as q the set of queries in q that exactly match any of the keywords in k i based on the query log information the set q yields a collection of clicked urls from which we selected those corresponding to blogs in the tumblr domain we denote such set of blogs as b to reduce data sparsity we filter out the blogs in b with less than two unique incoming queries in q or less than 3 clicks originated by them the set of queries hitting b is used to create a new set of keywords k i1 and to reiterate the procedure given the current set of deviant nodes b we identify the 10 of blogs with highest proportion of query hits that match words in k i those are the blogs that are hit mostly by deviant queries compared to other query types we select all the unique queries that hit those blogs and merge them with k i thus obtaining a new set of keywords k i1 which is used to feed the next iteration of the algorithm the procedure is repeated until the sizes of both k i and b converge the initial set k 0 is obtained as follows we first create a keyword set as the union of the search keywords from professional adult websites along with the list of adult performers published by movie production companies to extend the coverage also to blogs that are reached predominantly by spanish queries we also translated to spanish the initial set of keywords from this initial set we manually extracted two dictionaries of respectively 5152 and 5283 search keywords which were used to filter queries in the query log following two strategies 1 exact match selecting those queries in the query log which match exactly one search keywords in the first dictionary 2 containment selecting those queries subsuming any search keywords term in the second dictionary for instance the word porn is not included in the containment dictionary because queries like food porn should not to be detected as adult the union of the queries detected by the two strategies hits a set of blogs whose most frequent incoming queries were manually inspected to detect further 351 search keywords the union of these terms with the exact match dictionary leads to a set of 5503 deviant queries which is used as the seed set k 0 to bootstrap the deviant graph extraction the above algorithm is biased towards the query log data and on the popularity of blogs measured through the volume of search queries on the other hand this method allows to identify very quickly nodes that are likely to be relevant in the network as they produce the most interesting content to web users also as the procedure is networkoblivious no bias is introduced in our analysis of the network figure 2 shows that the deviant graph extraction procedure converges quickly we stop after 6 steps with 198k nodes hit by 42m unique queries the final vocabulary containing 7361 words is made publicly available to the research community1 in figure 3 we report the distribution of the deviant query volume ratio for the deviant nodes detected the distribution is skewed showing that about 30 of the nodes are hit by a majority of deviant queries to study the interaction of deviant nodes with the rest of the social network we extracted a subset of the tumblr follower and reblog networks with a snowball expansion starting from the 198k identified deviant nodes up to 3hops away the follower is a snapshot of the graph done in december 2015 the reblog network was built from the reblog activity happened in the same month statistics about the resulting networks are reported in table 1 we also obtained information about selfdeclared age and gender for about 17m tumblr users and in particular for about 10 of the detected deviant nodes the datasets include exclusively interactions between users who voluntarily optedin for such studies all the analysis we report next has been performed in aggregate and on anonymized data deviant graph in context the availability of data about the interaction between deviant nodes and the social network that surrounds them provides the unique opportunity to study the structure and dynamics of a deviant network within its context we first analyze the shape of the deviant network and measure its connectivity with the rest of the social graph we then look into how the information originating from deviant networks spreads across the boundaries of the deviant group last we study some demographic properties that characterize producers and consumers deviant network connectivity the deviant network is a tiny portion of the whole graph representing about 07 of all the nodes in the reblog graph we consider the deviant networks as the subgraphs of the follow and reblog tumblr networks induced by the deviant nodes a directional link in the follow network from node i to node j exists if i follows j meaning that the information flows from j to i basic network statistics on such subgraphs reveal that the deviant networks are quite dense yet they have a high diameter similar statistics have been observed before in other social networks and might be an indication of the presence of strong subgroups patterns as well as a signal of the absence of a community structure to better determine the reason for such elongated shape we run the louvain community detection algorithm on the deviant network2 four clusters emerge whose network statistics are summarized in the bottom lines of table 1 to determine their nature we manually inspected the content of 250 blogs in each of them more than 90 of all the blogs in the two largest clusters contain blogs that exclusively produce explicit adult content aimed at an heterosexual public or at a male homosexual public the blogs in the two remaining communities post less explicit adult content and more sporadically often by means of reblogging they either focus on celebrities or function as aggregator blogs with high content variety including depiction of nudity from a bidimensional visualization of the network layout it becomes apparent that the two bigger clusters are two wellseparated cores that give a characteristic hourglass shape to the network reason for the high diameter observed the remaining communities are peripheral and arranged in a crownlike fashion around the largest subcluster producers 1 we name the two smaller groups bridge communities as their main focus is not on deviant content but they are an entry point for deviant query traffic and as we shall see next act also as bridges towards the rest of the graph in short we find that deviant nodes are not scattered in the social network but are tightly organized in a structure of distinct communities to find out about the nature of their interaction with the rest of the social ecosystem we proceed to answer the next question q2 to what extent is the deviant graph connected to the rest of the social network there are several ways to estimate the connectivity between two sets of nodes in a graph we use different metrics to measure it between the four communities of the deviant network and the rest of tumblr as summarized by the matrices in table 2 rows represent the group of nodes from which the social tie originates columns those on which it lands the average volume of connections provides a first indication about the difference in connectivity across different groups the diagonal has the highest values because of the community structure of the deviant network and of its subcommunities members of a group have many more ties towards other group members rather than to the outside this is true in particular for the two producer clusters the volume of links incoming to the largest producer cluster is particularly high from the smallest bridge community which surrounds it the average tumblr user in our sample follows around 51 users between 2 or 3 of which are in the core of the deviant network and around 2 of them are in bridge communities similarly among the 33 users reblogged in one month by the average user one is from a producer cluster and one from a bridge group when looking at raw volumes the amount of links from the deviant network to the rest of the graph is very high mainly due to the high dimensionality of the set of nodes that are not deviant to partially account for dimensionality of the groups we measure the connectivity with density computed as the ratio of edges between the two groups over the total number of possible edges between them also in this case the overall patterns hold but the connectivity towards the external graph drops significantly values of density are still affected by size though it is known that in real networks there is a strong correlation between density and number of nodes to fix that in the spirit of established work in complex systems we resort to a comparison of the real network connectivity with a null model that randomly rewires the links while keeping the degree of each node unchanged the values we report in table 2 indicate how many times the number of connections observed deviate from the null model also in this case values on the diagonal are very high also this computation highlights that ordinary users have a tendency to reblog content from the core of the deviant network almost 7 times more than random and between 16 and 53 times more than random from the bridge community members in summary the core of the deviant community is dense but it is far from being separated from the rest of the graph which is connected to it both directly and even more tightly through bridge groups deviant content reach we found that although the deviant network forms a tightly connected community it is not isolated from the rest of the social graph this calls for an investigation about the visibility that the deviant content has in the outer network and what are the main factors that determine its exposure we do so by answering the three research questions below q3 how much deviant content spreads in the social graph and who are the main agents of diffusion the exposure to deviant content goes beyond the members of the deviant network who are the producers of original adult material specifically the consumers of deviant content can be categorized in three classes the first is the class of active consumers nodes who reblog adult posts thus contributing to its spreading along social ties posts can be reblogged in chains and create diffusion trees that potentially spread many hops away from the original content producer therefore active consumers could further be partitioned in those who spread the content directly from the producers and those who do it with indirect reposts the second is the class of passive consumers nodes who do not contribute to the information diffusion process but are explicitly interested in adult content because they directly follow the producer nodes the last class is the one of involuntary consumers users who do not follow any producer node and do not reblog their content but happen to follow at least one active consumer who pushes adult content in their feed through reblogging by drawing a quantitative description of the volume of deviant content reaching these three classes we can estimate how much the adult community is visible in the network at large we adopt a conservative approach in which we consider the two producers communities as the only ones generating original explicit content given the results of the aforementioned manual inspection we are very confident that their activity is completely focused on the production of adult material we measure the size of the different consumer classes and the amount of content that flows through or to them by means of reblogging the results are summarized by the schema in figure 5 the network of deviant content producers is very small but receives a considerable amount of attention from direct observers the audience of passive consumers counts almost 24m people around 2m users reblog directly from the deviant network for a total of around 28m reblog actions in one month a consistent part of the two bridge communities within the deviant graph are also direct consumers and they reblog producers 56k times per month when looking at the set of 24m users who indirectly reblog deviant content we see that only a small fraction of their monthly reblogs is performed through bridge communities however in relative terms bridge communities are considerably more efficient in spreading information than the average active consumer if we consider efficiency η of a user set u as the ratio between reblogs done r d and reblogs received r r weighted by the cardinality of the set η rr r d •u we discover that the bridge communities are several orders of magnitude more effective in spreading the content farther away in the network than the rest of active consumers last the audience of users who are potentially exposed in an unintentional way to deviant content includes almost 40m people this figure should be considered as an upper bound on the number of people who actually have been exposed as a follower of an active consumer might not see the pieces of deviant content for a number of reasons that said the pool of people who are potentially exposed is still very wide q4 what is the perception of deviant content consumption from the perspective of individual nodes similar to real life individuals in online social networks are most often aware of the activities of their direct social connections only but lack a global knowledge of the behavior of the rest of the population in fact the broad degree distribution of social networks may lead to the overrepresentation of rather rare nodal features when they observed in the local context of an egonetwork this phenomenon has been observed in the form of the socalled friendship paradox a statistical property of social networks for which on average people have fewer friends than their own friends more recently the concept has been extended by the so called majority illusion which states that in a social network with binary node attributes there might be a systematic local perception that the majority of people possess that attribute even when it is globally rare as an illustrative example in a network where people drinking alcohol are a small minority the local perception of most nodes can be that the majority of people are drinkers just because drinkers happen to be connected with many more neighbors than the average in our case study active deviant content consumption is definitely a minority behavior compared to the 130m users in our sample to estimate the presence of any skew in the local perception of deviant content consumption we consider the nodes who are not producers and calculate the distribution of the proportion of their neighbors that either produce or reblog deviant material the result is summarized in figure 6 we observe that the follower network is nowhere close to exhibit the majority illusion phenomenon with only the 10 of the population having 10 or more of their neighbors posting or reblogging deviant content the effect increases sensibly when considering the reblog network with 40 of the population locally observing more than 10 of their contacts reblogging deviant content and almost 10 having more than half of their neighbors doing it this happens partly because the size of the reblog network is one order of magnitude smaller than the one of the follower network as we consider reblogging activity for one month only still this means that when looking at recent activity only local perception biases are much stronger in the community than what can be inferred from the static follow graph although strongly biased perceptions are not predominant when counting the number of neighbors a stronger bias emerges when looking at the volume of deviant content that is observed by a node from its neighbors more than 71 of nodes reblogs less deviant content than the average of their friends this effect that de rives directly from the strong correlation between degree and number of posts and reblogs suggests that the local users perception of other peoples behavior is skewed towards an image of pervasive consumption of deviant content q5 is it possible to reduce the diffusion of deviant content with targeted interventions previous literature that investigated the properties of smallworld networks indicates that information spreading or other phenomena of contagious nature can be drastically reduced by acting on a limited number of nodes in the graph effectiveness of targeted interventions has been shown in a variety of domains epidemics being the most prominent among them the intuition informed by previous work suggests that the wide diffusion of deviant content can be reduced by properly marking the posts produced by a small set of core nodes and showing them only to people who explicitly declared their interest for that specific topic in a simplified experimental scenario we measure the proportion of active consumers reached by adult content in a setting where all the posts from a set of core nodes c are erased the question is how to select c and how big it needs to be to uproot the diffusion process the optimal selection of nodes is a set cover problem but we test two common approximated strategies to solve it i greedy by volume an algorithm that ranks nodes by the number of blogs that are reached by the content they produce and ii greedy by degree that takes into account the network structure only and ranks nodes by their indegree in the reblog network the effectiveness of the two approaches as c increases in shown in figure 7 although using the indegree as proxy for the diffusion potential is not optimal the removal of the 5000 highest indegree nodes curbs the diffusion by more than 50 as expected the strategy by volume is more effective with a surprisingly sharp decay of the deviant content reach the removal of the 5000 top nodes reduces the information spreading by nearly 80 which increases to almost 100 when extending the block to 25000 nodes furthermore using our sample of demographic information we find that to limit the exposure of underage users would be sufficient to remove the 200 top nodes as identified by any of the two selection strategies demographics factors the demographic composition of online adult content consumers has been measured by several sociological surveys but none of them partitions the participants according to their type of consumption yet we have shown that the categories of people exposed to online deviant content range from the active content producers to unintentional consumers this calls for an investigation of the relationship between type of consumption and demographic characterization q6 is there a significant difference in the distribution of age and gender between members of the deviant network and people with different levels of exposure to deviant content we report the distribution of age and gender of users with different levels of exposure to adult content computed on the sample of 17m users who selfreported their demographic information the average age in the sample is slightly higher than 26 and female are the majority to partly validate the userprovided information we first compare them with thirdparty statistics our numbers are roughly compliant with several public reports that rely on orthogonal methods for assessing the age and gender of users those show that the tumblr user base is the youngest among the most popular social networks and composed of women also we further validate the gender data by assessing that the 95 of users in the producer 2 cluster focused on male homosexual content are indeed male the overall age distribution of age by gender is shown in figure 8 male tend to be older originating a distribution with a fatter tail between age 35 and 55 despite the spikes corresponding to birthdays in round decades probably due to misreporting the distribution still tends to be gaussian as expected we then measure differences in age 3 and gender distribution for the user classes of producers bridges active consumers passive consumers and unintentionally exposed users producers are considerably older than the typical user averaging around age 38 and with almost no underage users different from the overall distribution they are mostly male in alignment with studies indicat 3 the number of samples in each age distribution is high therefore as expected all the differences between the average values are statistically significant under the mannwhitney test ing that men are more involved in assiduous consumption of adult material bridge groups are fairly genderbalanced and include younger people consumers of deviant nodes who actively reblog or passively follow deviant blogs are covered by demographic data at 12 proportion that drops to 4 among those who follow deviant nodes in both classes the age is quite representative of the overall tumblr population in our sample the same malefemale proportion holds for people that are potentially exposed to deviant content in an unintentional way this last class has the highest proportion of underage people which reinforces the concern about young teens unwillingly seeing inappropriate content the fact that the gender distribution for active and passive consumers deviates only slightly from the overall gender distribution is in partial disagreement with previous studies on gender and sexual behaviour which state that men are usually more exposed than women to adult material we conjecture that this might happen because of the tendency of female to have their peak of adult content consumption in a much younger age than men combined with the predominance of young female among tumblr users to verify it we aim to answer one last question q7 does age have an effect on how different genders consume adult content to find out we measure the proportion of male and female actively exposed to deviant content by age we apply a minmax normalization to the obtained values so that scores towards 0 represent the minimum level of engagement the curve for men shows an increasing trend that plateaus at its maximum in the range of age 35 to 55 in contrast women although less exposed than men at any age have their peak in their 20s much earlier than men this observation supports previous findings and explains the distributions we observed conclusions this work aims to motivate researchers who study all types of deviant communities online as well as offline to explore in more depth the interaction between the agents in such networks and the external social environment our contribution scratches only the surface of the exploration space that underlies the many types of deviant networks and the multitude of settings they are situated within the study we have presented is limited under many aspects beginning from the focus on a single type of deviant behavior adult material consumptionthat is much more pervasive than others and in that has unique characteristics that likely cannot generalize to other deviant groups in terms of methodology alternative techniques could be used to identify adult content without a dedicated dictionary those could possibly lead to describe the same phenomenon from a slightly different angle for instance considering more exhaustively nodes that are not reached by search traffic to address some of these points we plan to expand our study in both breadth and depth in future work we will consider multiple online platforms and multiple deviant network types at different scales also we plan on analyzing the temporal dynamics of the deviant content spreading along social links yet we believe that our study has already important theoretical implications in revealing for the first time on very large scale that deviant communities can be deeply rooted into the relational fabric of a social network and that the echo of their abnormal activity can reach a plenitude of ordinary users also from a practical point of view learning the effect that a minority group can have on a much larger audience is key to trigger mechanisms able to contain risky deviant phenomena by means of targeted interventions on few nodes as we have shown we believe that this work could set the basis for a line of study that could lead to a deeper understanding of deviant networks and of their impact on everyones life

online social networks are complex ensembles of interlinked communities that interact on different topics some communities are characterized by what are usually referred to as deviant behaviors conducts that are commonly considered inappropriate with respect to the societys norms or moral standards eating disorders drug use and adult content consumption are just a few examples we refer to such communities as deviant networks it is commonly believed that such deviant networks are niche isolated social groups whose activity is well separated from the mainstream socialmedia life according to this assumption research studies have mostly considered them in isolation in this work we focused on adult content consumption networks which are present in many online social media and in the web in general we found that few small and densely connected communities are responsible for most of the content production differently from previous work we studied how such communities interact with the whole social network we found that the produced content flows to the rest of the network mostly directly or through bridgecommunities reaching at least 450 times more users we also show that a large fraction of the users can be inadvertently exposed to such content through indirect content resharing we also discuss a demographic analysis of the producers and consumers networks finally we show that it is easily possible to identify a few core users to radically uproot the diffusion process we aim at setting the basis to study deviant communities in context

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introduction tobacco smoking is a serious public health threat and is an established risk factor for noncommunicable diseases including cardiovascular diseases chronic respiratory diseases and cancer 1 over the past three decades tobacco smoking has accounted for more than 200 million preventable deaths worldwide with the population of current tobacco smokers exceeding 1 billion 2 with this high number of tobacco smokers worldwide the who urged reducing tobacco use as it is quintessential to reducing the global burden of noncommunicable diseases which account for nearly 71 of global mortalities 3 tobacco smoking is a huge concern in lowincome and middleincome countries as 80 of tobacco smokers reside in these regions 2 4 specifically the southeast asian region accounts for nearly 90 of the total tobacco smokers across the globe 5 bangladesh a south asian country is one of the top 10 countries where twothirds of the worlds total number of smokers live 2 6 according to strengths and limitations of this study ► this study used the most recent nationally representative surveys with appropriate statistical techniques to estimate the change in tobacco smoking prevalence and associated factors ► our findings can be considered generalisable to the national population ► the inherent limitations of a crosssectional study design limited our ability to infer causality ► selfreporting of tobacco smoking data can be subject to information bias open access the most recent data more than onethird of the adult population in bangladesh smoke tobacco 7 previous studies have identified several factors associated with tobacco smoking for example parental tobacco smoking and media showcase of favourite television or film stars using tobacco smoking products are documented as significant predictors of tobacco smoking 8 9 studies from south africa 1 beijing 10 and bangladesh 11 have also identified other factors such as age gender marital status and level of education to be associated with tobacco smoking prior evidence from bangladesh has also indicated that 3 of seventhgrade to ninthgrade students smoke 12 this is worrying because more than half of teenagers who start tobacco smoking at an early age could become habitual smokers in later life predisposing them to the risk of noncommunicable diseases 13 acknowledging the high burden of tobacco smoking worldwide the who implemented the framework convention on tobacco control as well as the protocol to eliminate illicit trade in tobacco smoking products 3 the fctc is further iterated in the sustainable development goals particularly target 3a bangladesh is identified as the first signatory to the who fctc 8 the government of bangladesh has enacted the tobacco smoking and tobacco smoking products usage rule 2015 which includes increased price and tax on tobacco smoking products prohibiting tobacco smoking in public places and preventing the sale of tobacco products by and to minors 14 in addition in march 2021 the ministry of local government rural development and cooperatives released implementation instructions to guarantee that the tobacco control act is properly implemented by local governments this endorsed that all retailers have licences and limit locationbased sales along with other tobacco control steps 15 tobacco smoking constitutes the major form of tobacco use in bangladesh 16 it endangers human health while also putting financial strain on smokers thus a continuous watch on the prevalence of tobacco smoking must be maintained despite the legislative to control tobacco smoking in bangladesh it is unclear to what level the policies have been implemented over the years this suggests the need to track the pattern of tobacco smoking in bangladesh over the years it is also important to identify whether there was any change in factors associated with tobacco smoking therefore this study examined the change in prevalence of tobacco smoking and the factors associated with tobacco smoking over time among the adult bangladeshi population using two nationally representative surveys methods data sources and sampling frame we used data from the two most recent global adults tobacco surveys in bangladesh gats is a nationally representative survey that follows a consistent and standardised process 17 18 this surveys target population comprises all bangladeshi men and women aged 15 years and above a threestage stratified cluster sample of households was used for the gats 2009 survey the first stage involved selecting 400 primary sampling units using a probability proportional to size approach followed by a random selection of one secondary sampling unit per psu in the third stage households from a particular ssu were selected systematically from the list of households the gats 2017 survey used a twostage stratified sampling methodology in the first step eight administrative divisions were created with further stratification within each division based on the bangladesh bureau of statisticss categorisation of urban and rural enumeration areas then 496 psus from the 8 divisions and further equal allocation of psus to urban and rural stratum in the second step of selection 30 households were systematically selected from each sampled psu with an equal probability using the fractional interval technique finally one participant was picked randomly from among all eligible men and women in a participating household the gats 2009 and 2017 bangladesh survey report contains details about the data collection procedures methodologies and questionnaire 11 19 outcome variable current tobacco smoking was the outcome variable for this study all individual participants were asked does this person currently use tobacco including cigarettes bidi hukkah cigars or pipes the response was dichotomous independent variables selection of independent variables was based on a thorough literature review by the authors the independent variables considered were age sex place of residence level of education occupation household income whether tobacco smoking is allowed at home whether free tobacco smoking products are offered and whether participants had seen any tobacco smoking scenes in a moviedrama 20 notably drama is a 3050 min television programme that tells a story and is widely broadcasted in bangladesh statistical analysis we analysed each data set individually to determine compare and contrast factors associated with tobacco smoking all the variables used in the study were categorical and recoded where necessary after removing missing information from the variables the data were appropriately weighted to estimate the national tobacco smoking prevalence with 95 ci the outcome variables and the selected independent variables were tested for association using the χ 2 test p 005 was considered statistically significant to examine the association adjusted or with 95 ci was calculated using logistic regression open access finally multivariate logistic regression model was used to identify the factors independently associated with tobacco smoking aor with 95 ci was calculated then by computing the area under the curve we used receiver operating characteristic curve analysis to verify the performance of the models an roc curve portrays 1specificity on the horizontal axis and 1sensitivity on the vertical axis where auc represents model accuracy the auc value ranges from 0 to 1 with 0 demonstrating a completely inaccurate classifier and 1 indicating a perfectly accurate classifier an auc of 05 indicates that the model has no discriminatory ability generally the model is better to be fitted if the auc value is close to 1 21 the statamp v16 statistical program was used to conduct all analyses patient and public involvement no patients were involved results participants characteristics a total of 9629 participants in gats 2009 and 12 783 participants in gats 2017 were included in the present study about half of the participants were from rural areas and were female in both survey periods the highest percentage of respondents was aged between 25 and 34 years both in gats 2009 and in gats 2017 followed by the 3543 years age group more than onethird of the participants in gats 2009 had no formal education while this was about 2801 in gats 2017 about 40 of the participants belonged to poor wealth index families in both waves of the survey we found that 2416 of the respondents in gats 2009 were allowed to smoke at home while this was about 16 in gats 2017 distribution of tobacco smoking status for both gats 2009 and gats 2017 across the different subcategories of the study sample is shown in table 2 prevalence of tobacco smoking by participants characteristics table 3 shows the changes in prevalence of current tobacco smoking the overall prevalence of current tobacco smoking was 2300 in gats 2009 and 1644 in gats 2017 the prevalence was higher among men than among women both in gats 2009 and in gats 2017 the highest prevalence was found in the 4554 years age group in both survey periods participants with no formal education and who were involved in agriculture had a higher prevalence of tobacco smoking compared with other groups notably the prevalence of tobacco smoking decreased between gats 2009 and gats 2017 among all strata of participants except when the wealth index of the family is considered with regard to the wealth index of the family the prevalence of tobacco smoking increased between gats 2009 and gats 2017 among the rich while it decreased among those of poor and middle wealth status factors associated with tobacco smoking table 4 depicts the multivariate regression analysis of factors associated with overall tobacco smoking among adults in bangladesh we found that male participants were 59 times and 71 times more likely to smoke than female participants in gats 2009 and gats 2017 respectively adults and older adults had higher odds of tobacco smoking than young adults this finding was found to be significant in both waves of the survey the likelihood of tobacco smoking decreased as education level of participants increased where having at least primary secondary or higher education was associated with lower odds of tobacco smoking compared with those having no formal education students were associated with lower odds of tobacco smoking compared with unemployed participants both in gats 2009 and in gats 2017 surprisingly gats 2009 showed that participants from rich wealth index families were less likely to smoke than those from poor families however a reverse finding was detected in gats 2017 we also found that tobacco smoking being allowed at home and having no rules were associated with higher odds of tobacco smoking among adults in both surveys interestingly participants who were offered free tobacco sample products were less likely to smoke compared with those who were not offered such products both in gats 2009 and in gats 2017 when participants see anyone using tobacco smoking in a moviedrama scene 26 of participants in gats 2009 and 34 of participants in gats 2017 are more likely to smoke gats 2017 showed that selfemployed respondents were 42 more likely to smoke than those who were unemployed again participants from rural areas were less likely to use tobacco compared with urban residents but no significant association was found between place of residence and tobacco smoking in gats 2009 discussion the present study showed that the prevalence of tobacco smoking among bangladeshi adults declined by more open access open access than 6 between 2009 and 2017 this finding is consistent with a recent study in bangladesh 6 that noted a decline in the prevalence of tobacco smoking this shows that the pattern of tobacco smoking in bangladesh should be monitored in order to determine whether or not it is changing it is also crucial to see if any of the factors linked to tobacco usage have changed the observed change in the prevalence of current tobacco smoking from this study may possibly be explained by the effects of the tobacco smoking control policy in bangladesh such as the tobacco smoking and tobacco smoking products usage rule 12 furthermore increased health literacy among the general public over time elimination of all forms of advertising and promotion labelling of cigarette packs with warnings and religious obligations may have contributed to this decrease we found a significant association between gender and tobacco smoking in both gats surveys men had higher odds of tobacco smoking compared with women this finding aligns with other studies conducted in bangladesh 12 and malaysia 13 a plausible explanation for this observation could be the differences in social acceptability in tobacco smoking in bangladesh where tobacco smoking is not accepted among women but is usually indifferent to tobacco smoking among men 6 another cause could be the impact of modernisation which may provide boys greater independence than girls as well as easier access to tobacco products the results of our study also indicated that age was significantly associated with tobacco smoking adults and older adults had a higher prevalence of tobacco smoking compared with younger adults our finding is supported by previous evidence from bangladesh 18 20 which indicated a higher prevalence of tobacco smoking among older adults than younger adults this finding can also be explained by the social acceptance of tobacco smoking sociocultural or family environment or the way of life of older people 6 it is also not unlikely that tobacco smoking by young people in bangladesh may be underreported educational attainment emerged as a significant factor associated with decreased tobacco smoking in both waves of the survey consistent with a preponderance of studies conducted in bangladesh 22 23 we found higher odds of tobacco smoking among those who had no formal education compared with those who had at least primary level of education this is possible because formal education is likely to provide individuals with relevant health awareness on the health hazards of tobacco smoking which can influence their informed decision to avoid tobacco smoking however evidence suggests good awareness of the health impacts of tobacco smoking among smokers 6 sensitising students at all levels of the education system along with ensuring smokefree policies at educational institutions would assist in decreasing the burden of tobacco smoking in bangladesh unemployment also emerged as a significant factor associated with increased tobacco smoking this finding could be explained by the fact that increased psychological distress due to unemployment led to adopting unhealthy behaviours such as tobacco smoking 24 we also found that persons from wealthy households had lower risk of tobacco smoking compared with those from poor households this is consistent with earlier studies which showed a higher prevalence of tobacco smoking among individuals from lower wealth index households 18 25 individuals who were unemployed and belonged to the poor household could have adopted tobacco smoking as a conduit to escape the realities of their poor socioeconomic status and their environment could have an impact on their continued tobacco smoking behaviour interestingly in gats 2017 those in rich wealth index households had higher prevalence of tobacco smoking which could be due to their affordability to purchase tobacco smoking products as tobacco smoking prices increased between the two survey periods our findings also identified that participants who see anyone using tobacco smoking in a moviedrama scene were more likely to smoke than their counterparts this finding was in line with prior evidence which showed a strong association between watching favourite actors actresses using tobacco smoking products in movie and or drama scenes and increased tobacco smoking 8 9 we also found that the odds of tobacco smoking were high when tobacco smoking was allowed at home which could be explained by banduras selfefficacysocial learning theory indicating that individuals learn through observation and imitation 26 it is widely known that the use of selfefficacy theory in cigarette cessation has been examined in a number of publications 27 28 through motivational cognitive and decision processes selfefficacy beliefs aid in achieving desired changes 29 following a strategy in singapore in line with the selfefficacy theory in bangladesh we can adopt persontoperson behavioural support and skills training as well as develop evidencebased tobacco use cessation treatments for individuals and specific population groups who use tobacco 29 therefore implementing tobacco smokingfree policies in media might be effective in reducing the prevalence of tobacco smoking among bangladeshi adults the decrease in tobacco smoking prevalence between 2009 and 2017 in bangladesh might be demonstrated by several factors such as the impact of tobacco smoking control policies and advocacy increasing literacy rate and awareness of health consequences however our study identified a few areas for further attention which should be acted upon through a coordinated approach between the government of bangladesh and other nongovernmental organisations working on tobacco smoking control health literacy and antitobacco smoking campaigns could be targeted to highrisk populations such as those who are unemployed men and those aged 2565 years or older strong advocacy and lobbying can also be established among directors producers and media owners which are paramount in this regard open access because any laws and regulations do not put this issue in place of enforcement findings of this study could also assist the government in strengthening the enforcement of tobacco smoking regulatory frameworks 14 the strengths and limitations of this current study were prudently accredited first this study used the most recent nationally representative surveys with appropriate statistical techniques to estimate the prevalence therefore the study results could be generalisable to bangladesh in addition the results of this study identified factors of tobacco smoking and whether there was any change over the period of 8 years due to change in relevant tobacco smoking control policies the inherent limitations of a crosssectional study design limited our ability to infer causality second selfreporting of tobacco smoking data was subject to information bias third although we have used the most recent data of 2017 the most recent changes over the period of the last 4 years were not reflected in this paper conclusions the current study found a decline in the prevalence of tobacco smoking among the bangladeshi adult population over the period of 20092017 however it remained high among men older adults aged over 24 years those with no formal education and unemployed population appropriate interventions need to be designed particularly targeting men older population aged over 24 years and the less educated and unemployed segments of the community people follow media persons thus policies could be made so that media personnel cannot promote smoking moreover prioritising social and homebased health literacy programmes on the harmful impact of active and passive tobacco smoking as well as strict regulations of tobacco smoking advertisement could facilitate a faster decline in tobacco smoking in bangladesh md ashfikur rahman orcid org 0000000255178557 satyajit kundu orcid org 0000000196101479 bright opoku ahinkorah orcid org 000000017415895x joshua okyere orcid org 0000000340807522 henry ratul halder orcid org 0000000213623077 uday narayan yadav orcid org 0000000266261604 open access supplemental material this content has been supplied by the author it has not been vetted by bmj publishing group limited and may not have been peerreviewed any opinions or recommendations discussed are solely those of the author and are not endorsed by bmj bmj disclaims all liability and responsibility arising from any reliance placed on the content where the content includes any translated material bmj does not warrant the accuracy and reliability of the translations and is not responsible for any error andor omissions arising from translation and adaptation or otherwise

objective this study assessed the changes in prevalence and associated factors of tobacco smoking among bangladeshi adults over time design nationally representative crosssectional surveys setting two most recent global adults tobacco survey gats data from bangladesh carried out in 2009 and 2017 participants adult population aged 15 and above n9629 in 2009 n12 783 in 2017 outcome measures current use of tobacco smoke including cigarettes bidi hukkah cigars or pipes which was dichotomised yesno methods we analysed data from two recent rounds of gats 2009 and 2017 multivariate logistic regression analysis was used results the overall prevalence of tobacco smoking among bangladeshi adults was noted 2300 95 ci 2298 to 2300 in 2009 1644 95 ci 1643 to 1645 in 2017 being male adjusted or aor 5972 ci 4056 to 8793 for 2009 aor7117 ci 4108 to 12332 for 2017 age between 25 and 64 years all aors 2 and p 005 smoking permissible at home aor708 ci 588 to 852 for 2009 aor590 ci 534 to 695 for 2017 and watching tobacco smoking product use in moviedrama scenes aor126 ci 111 to 144 for 2009 aor134 ci 117 to 154 for 2017 were found to be significantly associated with increased tobacco smoking among adults both in 2009 and in 2017 however being offered free tobacco sample products aor066 ci 057 to 077 for 2009 aor087 ci 076 to 099 for 2017 and having primary secondary or higher education all aors 1 and p 005 as well as being a student aor016 ci 009 to 029 for 2009 aor032 ci 019 to 053 were associated with lower odds of tobacco smoking in both surveys conclusions although the prevalence of tobacco smoking has declined over the period it is still high among those who were relatively older men less educated and exposed to a moviedrama where tobacco smoking is promoted therefore appropriate interventions are required to stop tobacco smoking among the bangladeshi population

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introduction tourism is now an activity within the reach of millions and this has enabled the travel and hosting industry to flourish globally in particular islands are special places with a natural attraction for tourists due to their unique environmental and cultural attributes on many islands tourism is usually the answer to socioeconomic constraints contributing as the prime source of economic welfare and job creation for the locals who inhabit these isolated regions 1 intense and disproportionate tourism growth may however generate damaging environmental and social effects tourism pressures can endanger endemic species as well as generate friction in the local community as visitors may adopt behaviors that go against the island culture or traditional values 23 this friction may lead locals to dislike tourism and to develop coping mechanisms to avoid contact with visitors 34 generating unexpected consequences in the long run it is crucial that the growth of the travel and tourism sectors continues with the investment and development taking place in an open and sustainable manner motivating the empowerment of local communities and protection of cultural habitats 5 6 7 as seen in the work of dourish and foth et al 48 issues relating to nature or the environment have been the focus of several studies in hci research those studies have looked at how information and communication technologies may foster environmental sustainability behavioral change and social benefit the potential and effectiveness of hci interventions in ecofriendly practices require inquiry into the contexts in which those practices arise in hci research environmental and ecological concerns are typically framed as a psychological problem of bad habits where the solution is to motivate and inform people to act proenvironmentally 9 however environmental and ecological concerns go beyond personal or individual responsibility as they also have a political dimension that must be considered before eventually becoming part of any effective solution in hci interventions the contradictory dual reality of islands which heavily rely on tourism revenues but also struggle with the damaging effects of it provides a perfect example of what dourish calls the hci discourse that obscures political and cultural contexts of environmental practice which on the other hand must be considered as part of an effective solution 8 concerned with the interaction between locals and visitors towards environmental and cultural preservation this work uses as an example of analysis the archipelago of madeira an established tourist destination and home to the laurisilva forest in 2013 tourism accounted for 24 of gdp and 15 of employment in the region 10 this context led to the design of hávita an interactive web platform based on the concept of communitybased tourism ventures 5 which is defined as initiatives that aim to care for the environment as well as ensuring the empowerment of local communities through the fostering of interactions between visitors and locals the goal of the platform is to raise awareness of local values the natural heritage folk knowledge and traditions our main contributions for the interact community are i the description of the design and rationale of the hávita web platform ii the discussion regarding the benefits of such platforms for locals and tourists as we conducted studies with both groups and iii the discussion of the user feedback regarding the hávita prototypes and preliminary considerations for the future design iterations over the next two sections we describe the conceptual framework and related work that supported the motivation and design of the platform then in section 4 the design of the platform following a design research approach 11 is reported in section 5 we delve into the findings of several studies followed by a discussion of the findings against the empowerment framework and laying out preliminary reflections for future designers of platforms with similar goals to hávita conceptual framework in order to address the two different target groups in our study locals and visitors the design rationale of hávita draws on the combination of two different but complementary conceptual approaches to tourism first communitybased tourism 5 12 13 14 15 in which locals are the primary beneficiaries of the tourism second the authentic experience 16 a tourism trend that aims to provide unique and local experiences to tourists next we will explain how and why these concepts serve as the basis of hávita communitybased tourism and four levels of empowerment cbt looks at how local communities can exert control over the activities taking place in their environment based on past studies of how communitybased tourism 1315 tourism conducted and controlled by locals may empower local communities by diversifying the local economy generating entrepreneurial opportunities for residents from different backgrounds preserving culture conserving the environment and providing educational opportunities although one may say that cbt is related to the complex and broad literature on community engagement across different disciplines such as political science 17 and urban hci 18 the literature about cbt is quite developed and has been recognized in the context of tourism development namely sustainable tourism 1920 but also cultural tourism 19 and ecotourism 5 for the latter and aligned with the same concerns of our design rationales there is a specific branch in the literature called communitybased tourism ventures this refers to initiatives that aim to care for the environment as well as ensuring the empowerment of local communities this approach to ecotourism is a response to tourism activities that are controlled by outside operators foreign tourism companies or contexts in which most of the economic benefits fall naturally to the government rather than returning benefits to local communities 5 this approach is inspiring to our work since it prioritizes the quality of life of people and the conservation of environmental resources in the local community communitybased tourism is not however exempt from challenges and is often criticized by scholars 1219 this critical outlook of cbt is anchored in the problematic assumptions embedded within the community concept itself as noel salazar emphasizes in his work 19 within the literature on cbt 1219 and also community engagement 17 different authors criticize the idea of community as being a construct and vague and that is not taken into account by cbt studies blackstock 12 for example argues that the literature on cbt as presented since the 1990s fails in three major regards towards community development firstly it tends to take a functional approach to community involvement secondly it tends to treat the host community as a homogeneous bloc thirdly it neglects the structural constraints on local control of the tourism industry additionally manyara and jones 13 found several challenges for development of indigenous small and medium tourism enterprises some of these obstacles are access to the global marketplace literacy and numeracy sectorspecific skills access to capital resource ownership and lack of government support through appropriate policy and legislative framework 13 okazaki 14 concluded that to mitigate the failures of cbt the first step in tourism planning should be to examine the current situation with respect to community participation and then to indicate the initiatives that are required to promote it in addition to okazakis attempt to address issues found with cbt we recall the previous point made by blackstock 12 that we should focus on community empowerment and we draw on the principles or signs of empowerment proposed by regina scheyvens with regard to cbtv 5 she explains the signs of local empowerment and disempowerment derived from these four levels 1 economic empowerment cash earned is shared between many households in the community and there are visible signs of improvement economic disempowerment only a few individualsfamilies gain direct financial benefits from ecotourism most profits go to local elites outside operators government agencies etc 2 psychological empowerment selfesteem of community members is enhanced because of outside recognition of the uniqueness and value of their culture natural resources and their traditional knowledge psychological disempowerment many people have not shared in the benefits of ecotourism yet they may face hardships because of reduced access to the resources of a protected area 3 social empowerment social cohesion that may improve individuals and families as individuals and families work together towards the ecotourism activities social disempowerment the community takes on outside values and loses respect for traditional culture and for elders rather than cooperation there is competition for the perceived benefits of ecotourism 4 political empowerment refers to the structure that represents the needs and interests of all community groups and provides a forum through which people can raise questions political disempowerment the majority of community members feel they have little or no say over whether the ecotourism initiative operates or the way in which it operates drawing on these studies that have used the four levels of empowerment we anchor the analysis of our data to understanding how local communities in madeira might be empowered through the control of a digital media platform authenticity authenticity theory is connected with what van nuenen 21 presents as the modern discourse of antitourism which consists of a travelers desire to reach beyond superficial experiences that the tourism industry fosters van nuenen is drawing from goffmans theories dating back to 1959 22 in which goffman provides an analysis of social interactions framed by the metaphor of front and back regions of a theatre the front is the meeting place of hosts and guests and the back is where members of the home team retire between performances to relax and to prepare building on goffmans 22 division into front and back regions maccannell 223 says that touristic experience is underlined by the same structural tendencies increasingly tourists ambitions move towards experiencing the local life being like locals there is a desire to experience back regions and being one of them in this case being one of the locals or at least having access to the truth to the intimacy of locals what is relevant for us in having this theory as a framework is that part of this authentic experience involves a pursuit of more meaningful interactions with locals 23 in maccannells words the touristic way of getting in with the natives is the entry into a quest for authentic experiences perceptions and insights 23 this theory informs us not to design something that serves only as staged authenticity but a platform that enables visitors to engage with local life through developing ties with residents 3 related work interaction between locals and tourists past studies have revealed that the interaction between locals and tourists have developed in many forms and through different services and situations either online or offline 25 more recently this interaction between locals and tourists has been part of a broader discussion of what constitutes an authentic experience 223 for tourists 326 in the context of digital media and tourism echoing our context and design rationale moyle et al 25 explored the cultural interaction between local communities and visitors to islands using social exchange theory to enhance the understanding of the island experience in bruny island in tasmania and magnetic island in queensland australia the authors found that locals have a variety of motivations for social interaction with visitors ranging from solely economic to a genuine desire to share culture and traditions and avoid superficial and hostile contact however the most common reason for interaction was economic nevertheless those who do not rely on tourism to live often expressed a genuine desire to interact in order to provide quality and meaningful experiences it is also insightful to note that these authors point out that locals who have lived longer on the islands conceptualize the interaction with visitors as a process of storytelling either during an economic transaction or just socially for those pride plays a crucial role in interactions in which the sharing of history culture and environment is valued while the authors found that some locals blame tourists for the deterioration of local infrastructure they found a number of conditions that may facilitate the interaction between local and visitors such as festivals events and markets where locals could choose to interact with visitors with a time limit and without any major perceived threat to locals lifestyle these authors provide several suggestions that may inform our current work first the education of the island communities is relevant in order to prepare and adapt for a shifting global landscape in which visitors have more interest in experiencing each destination more holistically also the authors advocate for the inclusion of the visitors perspective in future studies about interaction between locals and visitors to small islands to date we have not found studies similar to ours that survey tourists in regards to the interaction between locals and visitors nor specifically on islands as a result our study fills a gap in the literature by not only adding the perspective of visitors in such interactions but also incorporating their impressions in the design of an interactive system while moyle et al talk about interaction between locals and visitors in general without making distinctions between online and offline interactions chung et al 2430 look at this type of interaction in online communities and the role of an offline meeting in building online friendships by using social network analysis chung 24 found that locals and tourists build friendships in an online community through offline events moreover they argue that that locals and tourists make their friendships in an online travel community but online friendships are likely to be formed after a facetoface meeting not only by online interactions on a note relevant to our project chung et al 30 conclude that the fact that online users generally build friendships after facetoface meeting provides destination marketing organizations with significant practical implications by developing the hávita conceptual design further we aim at not only providing information about nature and culture but also facilitating meaningful interactions with locals we push forward the trendconcept of designing digital media platforms for interactions between locals as we offer deeper contact with the locals way of living and raise awareness towards the local values furthermore this work also builds on and takes forward the recommendations of the work by moyle et al 25 and takes into consideration the feedback of both locals and visitors in the design of the platform designing the hávita platform for the design of the hávita platform we followed a research through design approach 11 we drew inspiration from the relevant literature on communitybased tourism the initial field research conducted when gathering the video content and the authors inside knowledge as active members of the local community 1 we also followed the advice of norman and stappers when political economic social and cultural variables interact it is best to proceed slowly with incremental steps 31 the development of the prototype evolved into two stages stage 1 describes the conception and content design of the platform based on the gathered literature informal interactions with local scientists local artisans with details in subsection below stage 2 subsection 42 describes how based on the video interview topics the platform allows visitors to engage in activities around the island that allow them deeper contact with the locals and their way of life 1 all authors were resident on the island at the time of the study and contributed equally to the design of the platform the first author is native and highly engaged in preserving local values and environmental care and she was the primary facilitator of the focus groups the second author has a background in journalism and extensive experience working with communities and conducted most of the interviews while informally involving the community in the project and was also one of the facilitators in the focus groups the third author is the principal investigator of the project with extensive experience in community storytelling and interactive media 41 stage 1 hávita 10 content creation we chose to produce video interviews as this format offers the visitors the sense to get to know community members and hear from them first hand utilizing the journalistic principle of having different points of view in a story we carefully chose our interviewees based on their expertise and knowledge on local heritage crafts and biodiversity the interviewees represented two different sources 1 scientific knowledge holders and 2 local folk knowledge holders all interviewees were informed of the general project goal to stimulate and instill in tourists an interest in the natural heritage and folk knowledge of madeira to scientists we asked openended questions regarding technical distinctions of terms such as native and endemic plants or the causes of wildfires or floods on the island to local residents we posed general questions about their knowledge and experience with the flora fauna and traditional products of madeira the content and thematic areas addressed in the platform were directly affected by the interactions with the locals as they generated a snowball effect for content development locals suggested themes and stories or put us in contact with other locals that they thought could contribute to the platform after three months of work we managed to gather 18 interviews of various length the content and themes of which was analyzed and yielded seven main categories laurisilva madeiras fauna traditional products hydrological balance macaronesian forests invasive species and natural disasters conceptualization of the interface the hávita homepage presents a promotional video introducing the platforms main goal the top of the page contains a dropdown menu where clicking on the word episodes leads to the identification of the seven themes drawn from the interviews and extensive interactions with the locals the icons in the dropdown menu expand and by clicking inside the expansion the visitors are forwarded to the page where the locals express their knowledge regarding the chosen topic the interface was deployed in a customized wordpress template hávita 10 provided us with a working repository of video content and interviews with the local community in a nonlinear modular fashion at this stage the communication between the visitors and the locals was still quite restricted being only granted through comments to the videos in order to enable a sense of empowerment of locals through the interaction with visitors we needed to make the platform more interactive stage 2 hávita 20 past studies have suggested 25 that direct involvement of local communities in touristic activities could benefit both visitors and locals on the visitors side it would provide the opportunity for an authentic experience and for the locals it would provide empowerment in fig 2 the connection between local empowerment tourists nature and the islands cultural values is present locals can be contributors not only concerning content for the main themes but they can also contribute by organizing activities those who contribute to the video content appear to the right side of each video below the picture there is a highlight if the local offers an activity by clicking that section visitors will be able to see which activity is proposed visitors can also have an overview of all locals participating in the platform while locals have access to a backend allowing them to manage their connection with the visitors evaluation of hávita platform the overall concept and design of hávita were evaluated in several stages we ran a pilot test with visitors of the island to gather first insights followed by a series of focus groups with three distinct user segments the local residents the local scientists and the tourists in the next section we describe this process of evaluation and its findings pilot study of hávita 10 the pilot study aimed at testing the research protocol as well as evaluating the effectiveness of the content on the users and finally the website graphical user interface a table was set up in a hotel lobby with a computer and tablets researchers invited the guests to interact with the platform a semistructured interview was designed to probe into three main areas a content b interface c connection with locals the whole protocol lasted 1520 minutes 12 european guests age range 14 to 65 participated in the pilot and were rewarded with a locally produced vegetal sponge interviews were recorded and later transcribed into nvivo software main results are summarized in table 1 table 1 results of the pilot study grouped by nvivo nodes and illustrative quotes platform content 1 design and interaction were simple 2 participants enjoyed and found the content shared by the locals relevant 3 scientific content was valued to confirm knowledge obtained during their explorations 4 videos featuring the locals sharing folk content was perceived as being authentic 5 hávita had enabled them to gather new knowledge about madeira and its ecosystem 6 added motivation to explore the island more 7 participants imagined accessing hávita before and during the travel psu1she is really authentic i could meet her out in the street and she would just talk to me like this… pb1i havent realized it been so many natural disasters deforestation so thats what i discovered and i also feel sympathy for the people who were caught in the natural disasters… pji1i was unaware of all this unique nature there is more than you realize different birds plants different species psu4i think the combination of being out there and then catching up with background is very good improvements 1 include advice on what to do or not do in order to preserve local nature biodiversity and traditions 2 videos should be tied with locations around the island 3 add a clear message about the website goal 4 add a short textual description before the video summarizing the subject psu6it is simple to navigate and go around it pgh1 interesting videos but it doesnt become clear what you want to tell me psit1just tell us want we can do … people dont like to think… visitors and locals interaction 1 the videos triggered curiosity about the locals 2 some participants felt prompted to interact with the interviewee while locals or others foresee difficulties in the communication and logistics ps2 i would ask the best places to go about to finding about locals what they are doing maybe there are traditional festival going on if there is something very special happening psu7the poncha lady i think that is really authentic i would ask for recipes how to find the herbs out in the trails pa1not really only between a group of friends but not me myself psh2that is very difficult because they obviously speak a different language implications of the findings for the hávita design and followup study while the platform was generally well received visitors are transient individuals and do not usually have time to divert from their holidays plans as a result most of them engaged in the study in a rushed and reluctant way echoing 25 findings therefore we changed our method to a focus group discussion in order to have participants committed to discussing the platform for a longer period of time and to probe more indepth opinions focus groups study the new study was designed to understand how different stakeholders would respond to the concept of the hávita platform involving local community members who held popularfolk knowledge local experts and visitors of madeira island the sessions were moderated by two facilitators and two assistants who helped in the setting up and documentation of the sessions sessions were recorded both in audio and on video observations and nonverbal interactions were noted design of the focusgroup session the facilitator presented the general purpose of the focus group introduced the research team and gathered consent forms this was followed by an icebreaker activity and then the hávita platform was showcased projected onto a large screen followed by a discussion designed to elicit comments and feedback on the platform throughout the text we have replaced the participants names with identity codes referring to which fg and the id of the participant visitors 6 females and one male with ages ranging from 24 to 44 all participants had a higher education degree 2 participants were portuguese 1 romanian 1 italian 1 german 1 turkish and 1 spanish ics fvmm fvmf fvia 60min 7 results in this section we present the main results from the focus group all fg were recorded and audio files transcribed the resulting data was analyzed by two researchers using a thematic analysis approach supported by nvivo software firstly researchers used open coding to create highlevel categories individually then reviewed and merged their separate efforts into new common categories secondly the researchers grouped the information into affinity diagrams used to explain the relationships between categories thirdly researchers organized the most frequent concepts and insights found for each focus group followed by the description of each one with illustrative quotes given by users in the interviews we will present the results from each focus group separately the overall findings and discussion are presented in section 6 positive reactions of the community to the multimedia content of hávita platform 1 participants enjoyed watching its content and felt proud of viewing the local community members featured in the video interviews 2 most enjoyed videos the laurisilva video the traditional products explained by locals themselves and the exotic species video 3 the community members expressed a desire to collaborate in producing further content and suggested several topics they would like to contribute to flc1 this is a great initiative… will you continue making more videos flc2 we have great things why not showcase them to others… flc1 more wickerwork its a local handcraft and a thing they might like here are also women who know how to embroider by showing the embroidery of madeira hávita a catalyst for interaction between the local community and visitors 1 par ticipants were very open to and happy with the idea of having a deeper and more authentic connection with the tourists 2 participants recognized in the hávita platform an opportunity to share the local culture eventually leading to attracting people to the small village and retaining them apart from festivalsparties tourists visit the location just for sightseeing purposes spending little time in the village itself 3 participants were excited about the idea of organizing workshops for tourists and immediately started brainstorming types of workshops the workshops would be very valuable not only for economic reasons but also to keep traditions alive they mentioned that some of the customstraditions are being lost since younger generations are not interested in them however if there is potential in the workshops they might change their minds 4 the local community also expressed interest in learning something from the visitors flc4 we want to welcome them all as long as theyre good people flc3 promoting the products would be a great help its very important its good for the local business to expose the parish itself flm complementing because we dont want tourists who arrive here to stay only for 5min have a coffee and leave flm2 its not just about selling the baskets there must be teaching and learning flm1 the workshops could be also a way to attract youngers to learn these crafts… at first could be just for fun but then they might enjoy it fla4 this godmother of mine would love to make some chestnut soup to dry and tread the chestnuts fll1 more wicker work its a local handcraft and a thing they might like there are also women who know the embroidery of madeira concerns 1 participants were worried that such a platform could not be developed in time within their lifespan that would be something more for their children or grandchildren to take advantage of 2 participants expressed that they would not be able to interact with the digital platform to add information videos or propose workshops and they would need help from their children or grandchildren fla6 its too much work for us it would have to be my daughter or mr manuels daughter its difficult for us table 4 summary of the local experts focus group hávita general impressions 1 local experts enjoyed hávita and considered it a good start to be further expanded they found the content interesting and dynamic except for the natural disasters which was labeled as too sensitive to be disclosed to the visitors in this open way 2 participants valued the initiatives that promoted the connection between tourists and locals through organized workshops as it would help support locals small business initiatives as well as farming and agriculture participants mentioned that these types of connecting activities would make visitors care about the location and revisit madeira 3 participants found the idea of a network of contacts activities and people novel and worth pursuing concerns and future suggestions 1 some of the local knowledge holders may present a lack of familiarity with technology and foreign languages and this should be taken into account in future iterations 2 several political issues were mentioned such as more government intervention and support to preserve the local natural heritage hávita could work as a place where locals could publicly emphasize threats to the environment in order to draw the attention of the government 3 experts worried about the popularity of madeira as a tourist destination and how that is affecting the resources of the island 4 participants suggested that hávita could have the role of an educational tool regarding the local values 5 participants suggested to highlight the features that support direct communication and interaction between locals and visitors furthermore a calendar showcasing activities would facilitate planning and participation before reaching the destination ferq1 it ferp7 everyone wants to gain from the tourism but they dont want to protect the product of madeira its nature locals don´t participants in the volunteering activities ferp8 tourism need to be educated eg not to pick plants feed birds and not to go on trails who are closed they need to learn the household rules fecn2 even though i work for the government… it needs to be educated as well ferp6 similar to other cities limits must be imposed … if we dont preserve and limit … everything will be destroyed appreciation for the authenticity and dynamic content 1 participants appreciated how the information was presented in an informative and timely way and how the short and dynamic videos help to keep the focus on the content in particular they enjoyed the authenticity of the local people featuring on videos and the mix between popular and scientific knowledge in particular the experts reasoning as opposed to an emotional perspective 2 participants mentioned that the platform can become a powerful database of knowledge and they mentioned padre nóbrega who passed away soon after releasing the interview with the hávita production team 3 participants also shared that they learn new things about madeira from the video content several users highlighted the richness of information and authenticity value of the video about the exotic plants the medicinal plants and the video explaining the origins of poncha fvia i also like that idea that you put normal people in the videos that is really cool it is nice to have experts but also just the locals… it gives a sense of authenticity fvmf2 the graphic elements helped to retain the information of what the people were saying fvia2 its like dynamic this moderation between the videos fvmf3 that database that recorded knowledge because that priest already died right his way of presenting information is really interesting you see he really feels passionate about it suggestions to strengthen the hávita platform and stimulate the connection between visitors and locals 1 the activities proposed by the locals should be laid out clearly so echoing the experts group participants suggested a more efficient way to present the activities for example in a calendar or a map so that visitors could plan the activities according to their stay 2 expand and add more content and topics there could be a crowdsourcing component where people could submit their videos about specific topics 3 use infographics to summarize the information from specific videos finally they expressed the desire to have more videos inside each of the main categories and express the interest in having fun facts or curiosities that could be added as text or images in the webpage of each main topic 4 in terms of the design and videos of the website participants pointed out small improvements such as the quality of sound in specific videos keeping the consistency between videos in the flow and pace of the content fvia5 for community spirit sometimes dont need the same language i feel like if you really want to do something you do fvmf3 put there like lady doesnt speak english but its a fun activity or youre gonna meet the locals its a very interesting experience fvga1 you could write as a traveler what is the benefitcontribution is it the time is the place it takes one hour or tell me that you will bring me to this place where i have never been before fvsg1 little more information about the people who speak and maybe a little bit of summary of the content in the beginning or after fvmf4 if we could see the map of madeira and activities and everything that they are talking about we can know where about discussion the section is divided into three subsections 1 enabling local empowerment where we discuss the potential for hávita to empower residents through the four levels of communitybased tourism 2 authenticity and visitor experience discusses to what extent tourists found the content and experience that the platform offers authentic and 3 preliminary insights and general lessons learned distilled from our experience that inform the development of similar platforms with the design rationale of raising awareness about local values while fostering connections between locals and visitors enabling local empowerment economic empowerment in the fgs locals especially those from nuns valley expressed a striking enthusiasm and willingness to organize activities for visitors such as workshops tours and visits to specific local areas although our participants did not stress economic benefits per se they were open to engaging with visitors through hávita and receiving a financial reward for the activities they could eventually organize for example locals were interested in the possibility of charging visitors for events such as wicker basket workshops as well as benefiting from a fair favor exchange visitors could for instance engage with locals from less urbanized areas in a fair exchange such as helping out in the winemaking and then receive a traditional lunch a platform like hávita could add value to the community and location by proclaiming new and authentic activities for tourists to engage in it could also lead to an indirect economic benefit that would come from the spread of the destination positive image psychological empowerment during the fg in nuns valley locals showed pride while watching their community represented on hávita through their comments and facial expressions they voiced that the platform was a powerful means to showcase local traditions to visitors for this reason several participants said out loud that they wanted to further contribute with novel content they also proposed activities in which they could share their culture and crafts this need for more information was later on reinforced in the fg with visitors in which they recognized how the multimedia part of the platform could become a powerful database of knowledge based on these results hávita could function as a selfesteem empowering tool for the community members because it highlights values of the local culture natural resources and traditional knowledge social empowerment in our fgs hávita emerged as a potentially socially empowering tool by improving individuals and families cohesion while working together towards the ecotourism goals and activities locals in nuns valley mentioned how such a platform could be used to trigger youth interest and instill pride in learning old customs and traditions elderly participants manifested a need for having the assistance from their children or grandchildren to use hávita and communicating in foreign languages on one hand this lack of digital literacy and foreign languages could be seen as an issue but it could provide the local community with bonding opportunities across generations as they work together leading to an improvement of digital literacy for those elder locals the fg with locals revealed a certain level of disempowerment of the locals from their words companies are basically the only entities that profit from the tourism but do not take action to protect the main product of madeira which is nature and culture political empowerment in the fg with scientific knowledge holders participants spent a significant time discussing how hávita might support community political empowerment they discussed how the platform could provide themselves with a forum in which people could speak out about pressing issues allowing them to address the regional government to raise questions and suggestions these participants were very concerned with tourism policies and pointed out the need to raise the regional governments awareness towards nature and traditions these findings led us to further envision hávita as a potential channel of social and political change this would address the concerns of di salvo et al 9 and manyara et al 13 and could generate collective action by influencing policy and regulations regarding tourism and environmental preservation and awareness authenticity visitor experience in general our results suggested that visitors perceived the video content as authentic and engaging participants appreciated hávita as a medium that offers insights into the cultural background of the local community and nature through video content in this way our findings reinforce our design rationale of providing starting grounds for interactions with locals such interaction could even begin before arriving at the destination as suggested not only by several participants but also by moyle et al 25 likewise hávita could allow alternative touristic experiences benefiting those visitors wanting to enter back regions of the locale 15 but also promoting alternative routes and situations eventually taking pressure off some of the most visited places indeed our findings showed that most of the visitors that we engaged with were surprised to learn about the islands difficulties tourism boards webpages often promote destinations as immaculate places and as visitors learned about alternative facts it contrasted with the paradise image of the destination they held before the visualization of hávita at the same time however the experience of browsing hávita brought the visitors closer to the authentic reality of the island our findings suggest that hávita shone a light on the islands values not only for visitors but also for the rest of the stakeholders locals and visitors both manifested an interest in extending and regularly updating the hávita content this resonates with what novacek 32 suggested that by utilizing multimedia content we were able to engage the public not only in the biodiversity of the island but also with its traditions and folk knowledge moreover visitors found the content interesting because it added to their touristic experience and local field trips while local experts praised the website for its ecological and local values message we were also encouraged to be more assertive and clear when posting these messages making clear calendars communication channels and information more easily available establishing connections between visitors and locals does not come without challenges something that has been previously approached in the cbt literature 13 locals may have unique expertise but may not know how to share it with visitors as seen previously this could be related to digital literacy issues or due to language barriers the latter was also a concern shared by visitors however they were open and willing to make efforts to overcome this summary of preliminary insights design for local values conservation valorization and authenticity local values can be lost over time hence it is crucial to continually capture and preserve ephemeral and intangible heritage video interviews with local testimonials revealed themselves to be a great way to promote empathy and connection between visitors and locals designers should leverage the pleasure of teaching and pride that locals have towards their local values promote a balance between folk and scientific knowledge and between reason and emotional content if possible complementary media such as infographics animations and visual summaries should be used to help viewers retain information design for digital literacy and intergenerational exchange locals enjoy seeing themselves their products and people they know personally represented on the platform however digital literacy may be one of the biggest challenges for future design iterations of hávita and similar platforms future design efforts could mitigate this challenge by facilitating intergenerational exchange and interaction for example through participatory design workshops besides this the design process of such platforms should support elderly people and younger generations to cocreate content and activities together which could be also promoted in workshops design for platform prosperity at the current stage hávita only has content produced by the researchers themselves in order to ensure sustainability of such a project content creation workshops could be delivered to locals so they could also contribute with content creation another approach is allowing crowdsourced content and subsequent monitoring mechanisms to ensure its quality future design efforts should delve into analyzing what would be the best format for the platform whether a website or a mobile application further research should address if locals would be more comfortable in adding activities and content by using a custommade application available on their mobile phones concerning the visitors experience designers should cater for different stages in the visitor experience prior to the arrival to the location but also during their stay the design may leverage for example on a supplementary mobile application that supports a visitors stay on the island by triggering relevant content based on their whereabouts furthermore activities promoted by locals should be laid out clearly so that visitors know exactly what to expect when of volunteering activities locals should clearly state why they are important and what difference they will make towards the local community design carefully around ctb problematic issues by opening up to dialogue we must acknowledge the risks and drawbacks of fostering communitybased tourism and design around such things as exploitation of visitorslocals imbalance between the offered experience and the cost addressing political concerns in its content and ensuring that locals have the means to control the benefits of exchanges with visitors designers could consider deploying strategies such as the integration of testimonies and evaluation of the proposed activities and hosts future iterations should account for exchanges of information between locals visitors and government regarding problematic issues by providing open communication channels like forums of discussion future work finding the best strategy to reach out to tourists who are transient individuals and usually do not have much spontaneous time to spend remains an open challenge in the next iterations of hávita we aim to include a more significant sample and quantitative data drawing for example on hávita data generated through google analytics furthermore it is important to realize that it will be hard to fully achieve our goal of empowering locals and stimulate interactions between locals and visitors with design or video interviews only it should be aided as suggested by di salvo et al 9 by administration collectives at the regional and national level these local partners as in the case of the regional tourism board may be able to facilitate the longterm engagement of both locals and visitors with the platform such steps would be fundamental in order to plan and run longitudinal studies for the platform finally it would be crucial to thoroughly study how to achieve some sort of sustainability of the platform itself and the impact of such a platform both on the visitors experience and on the local ecosystem conclusion in this paper we presented the design and discussion of an hávita an online platform aimed at fostering awareness towards local nature and folk knowledge as well as fostering connections between visitors and locals we presented our design approach and then discussions derived from our studies in connection with the presented theoretical framework this work makes specific contributions by further developing the trend of providing visitors with an authentic experience that not only has the potential to benefit the tourist experience but also to empower the local community furthermore we are filling a gap in the literature by adding the perspective of both visitors and locals in the interaction between them and laying out the barriers and strategies of undertaking user studies with visitors finally we provided a discussion that may inform the design choices of future platforms with similar goals

more people are traveling than ever before this intense and disproportionate growth in tourism may however generate negative environmental and social effects especially on islands in order to address this issue this article presents the design and evaluation of hávita an interactive web platform whose goal is to foster awareness of local nature and folk knowledge and create connections between locals and visitors we explored these design goals through different research methods such as user studies with tourists in hotel lobbies as well as focus groups consisting of two different groups of local residents and a group of visitors theoretically hávita is grounded in the concept of communitybased tourism ventures which is concerned with environmental preservation via ecotourism practices and at the same time the empowerment of local communities furthermore the design rationale of the platform is also inspired by the authenticity theory which examines tourists pursuit of meaningful interactions with locals our results indicate that despite time constraints for visitors locals and visitors were willing to interact with each other as they acknowledged authentic benefits in such interaction furthermore our focus groups with locals have shown the potential to stimulate different levels of local empowerment based on the communitybased tourism framework in the design iterations of hávita

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introduction t he covid19 pandemic has been an unprecedented shock to the world however the spread of covid19 has varied drastically between countries and regions while previous studies have emphasised several important factors associated with the spread of covid19 and strategies to reduce transmission few studies have focused on the social and cultural factors that may influence the spread of covid19 in this study we seek to address this gap by analysing the spread rate of covid19 from a crosscountry cultural perspective as a fundamental part of an individuals thoughts actions and interactions with others culture influences behaviour economic activities and social norms members of a cultural group behave and socialise according to their shared values and beliefs certain governmental policies may also be a product of culture so cultural differences may shape different regional attitudes and collective actions in response to the covid19 pandemic and further shape the regional differences in the severity of covid19 infections 1 for example in east asia such as south korea japan and china where the priority is given to obligations duties and the collective welfare people are more willing to tolerate personal inconvenience and wear masks during the pandemic however in the us where the priority is given to personal convenience and freedom people are less willing to follow the social distancing rules and wear masks people who value personal freedom would also be less likely to support lockdown policies and obey stayathome orders than people who value collective welfare as a result lockdown policies may fail to effectively slow the spread of covid19 when people are concerned with personal freedom therefore it is of great theoretical and practical significance to explore the effects of cultural factors on the spread of covid19 in this study we aim to address the following research questions do countries and regions with collectivistic confucianoriented or tight cultures have a lower growth rate of covid19 cases than countries with individualistic nonconfucianoriented or loose cultures do the cultural effects become stronger during lockdowns we investigate the association between different national cultures and the prevalence of covid19 cases by conducting a comprehensive crosscountry analysis national culture refers to the shared psychological beliefs and collective practices that distinguish one nation or region from another cultures have many dimensions that are difficult to quantify in this study we first capture national culture using the individualism index from the hofstede national culture measures to quantify collectivism vs individualism we believe the collectivistic vs individualistic axis is the hofstede cultural dimension most relevant to the covid19 global pandemic 2 this dimension measures group integration as the degree of perceived obligation and dependence upon a broader group felt by individuals within a society collectivistic cultures emphasise the we rather than the i and so stress the common good over personal interest they create ingroups based on the tightly integrated relationships among families and close friends as a result mask usage was higher in more collectivistic countries during the covid19 pandemic the importance of adhering to social norms and honouring the common good has also been demonstrated in the response to other collective crises such as global climate change anecdotally to reduce the spread rate of covid19 in the uk the scientific advisory group for emergencies recommended that the uk government should promote a sense of collectivism all messaging should reinforce a sense of community that we are all in this together 3 next we consider how the confucian vs nonconfucian orientation of culture influences the spread rate of covid19 collectivistic behaviours are an inherent component of confucian culture in east asia as confucianism dictates that to achieve the ultimate objective of social harmony one must place ones own interests and desires beneath the common good of the group confucianism emphasises the importance of collectivism and promotes shared social norms and virtues we also consider a tight vs loose culture the former has many strong norms and low tolerance for deviant behaviour whereas the latter has weak social norms and high tolerance for deviant behaviour variations in cultural tightness and looseness reflect the strength of punishment and degree of permissiveness and are determined by distal ecological and historical factors such as population density resource scarcity and disease and other environmental threats consistent with our expectations we find that countries and regions with collectivistic confucianoriented or tight cultures have a lower growth rate of covid19 cases than countries with individualistic nonconfucianoriented or loose cultures this remains true after controlling for factors associated with an increase in covid19 cases including national or regional population age structure gross domestic product per capita previous sars occurrence smoking prevalence and religion for every one standard deviation increase in our collectivism score the weekly growth rate of covid19 cases decreases by 138 in our sample more importantly we show that the cultural effect on slowing the spread of covid19 becomes stronger during national or regional lockdowns for every one standard deviation increase in collectivism score the weekly growth rate of covid19 cases decreases by 404 during lockdown period and it decreases by 124 during nonlockdown periods our finding of a significant cultural effect on the reduction of covid19 death rates across the world corroborates these results our study contributes to the existing literature in the following ways first prior studies show mixed results regarding the relationship between collectivism and covid19 cases webster et al report that countrylevel collectivism has no significant relationship with covid19 cases after controlling for covariates when only studying the united states webster et al even find that statelevel collectivism positively relates to both covid19 cases and higher deaths after controlling for all covariates except race however jiang et al and maaravi et al find opposite results and report that collectivistic societies have less covid19 cases than individualistic societies compared with webster et al maaravi et al and jiang et al we focus on the growth rate of covid19 cases rather than the number of covid19 cases we believe that it is worth exploring the growth rate of covid19 cases rather than the number of covid19 cases because the spread of covid19 is dynamic and changes over time and we can examine when cultures play a more important role in limiting the spread of covid19 by studying the growth rate our innovative perspective shows that countries and regions with collectivistic tight and confucian cultures experience a lower growth rate of covid19 cases this can be attributed to the emphasis these countries place on the ideas of the common good and sense of community as well as strong norms and low tolerance of deviant behaviour second our study contributes to the literature by showing that the degree of collectivistic orientation affects not only the spread of covid19 but also the outcome of lockdowns we report that the effect of collectivistic cultures on the spread of covid19 becomes stronger during lockdowns suggesting that lockdowns are more likely to succeed in slowing the spread of covid19 in countries and regions with collectivistic cultures therefore our findings successfully explain why stringent government policies can effectively slow the spread of covid19 in east asia where people share a strong commitment to collectives such as country community and family but only have limited effects on the spread of covid19 in western europe and north american where people endorse individualism and are independent third our study has important practical implications our findings indicate that government policies that focus on collectivistic considerations the concept of common interests community awareness and a low tolerance for deviant behaviours may more successfully slow the spread of covid19 as people all live together in a small global village overall as one of the most fundamental influences upon individuals thinking actions and interactions with other people culture and social norms affect national and individual responses to the covid19 pandemic our study is particularly important considering that many modern scholars these days hesitate to attribute outcomes to culture 4 data sample and variables to provide a comprehensive analysis of the cultural effects on covid19 spread rate we obtain daily covid19 case data from the our world in data website and individualism scores from the hofstede national culture website 5 6 we use hofstedes cultural dimensions to measure national culture because hofstedes cultural dimensions have been widely used in prior literature as some areas with reported covid19 cases do not have individualism scores our sample includes 190 countries and regions with reported daily counts of covid19 cases from 22 january 2020 to 31 december 2020 with 55184 countryday observations 7 two key variables are covid19 weekly case growth rate and the collectivistic culture measure based on the hofstede individualism scores indicating whether a country or region is primarily oriented toward a collectivistic or individualistic culture the weekly case growth rate for a country i on a day t is calculated as follows case growth it ¼ lnð1 þ covid cases it þ à lnð1 þ covid cases ità7 þð1þ where i and t index economy and day respectively covidcases it and covidcases it7 represent the number of confirmed cases in economy i on days t and t7 respectively ln is the natural logarithm of one plus covidcases it while ln is the natural logarithm of one plus covidcases it7 with this definition we obtain the growth of covid19 cases from a day in the prior week to the same day in the current week this calculation mitigates the potential bias associated with case reporting differences over weekdays versus weekends in the us and other countries since people in collectivistic cultures are more likely to take covid19 prevention measures and sacrifice for the common good we consider the role of collectivistic culture in limiting the spread of covid19 collectivistic culture is measured as the reciprocal of the logarithm of the hofstede individualism scores collectivistic ¼ 1 ln individualism ð þ ½ð2þ we provide collectivistic culture scores for all countries and regions in appendix b to conduct further empirical analysis we also identify countries and regions that belong to the confucian cultural circle as an additional measure of national culture the confucian philosophy of the common good emphasises the honour of collectivism and discourages individualism in interpersonal interactions in a society according to ye et al the countries and regions within the confucian cultural circle are china hong kong indonesia japan south korea malaysia the philippines singapore thailand and vietnam we create confucian a dummy variable that equals 1 for these ten countries and regions and 0 for all other countries we then use this dummy variable in the regression specification numerous studies have investigated factors associated with the spread of covid19 including population age structure gross domestic product per capita previous sars occurrence smoking prevalence and religion consistent with these findings we include the following control variables in the regression equations ln smoke sars age65 ln protestant catholic and muslim also the enforcement quality of policies may play an important role in effective pandemic response we include ln in the regression such that higher values indicate lenient or weaker enforcement of government policies we obtain the religion data from la porta et al the definitions of these control variables and data sources are provided in the appendix a table 1 reports the descriptive statistics of the main variables used in the study all of the continuous variables are winsorised at 1 and 99 the mean spread rate of covid19 is 2048 with a standard deviation of 3576 the maximum weekly growth rate is 20716 the average weekly growth rate of deaths is 1397 with a median of 470 the mean score of collectistic for the sample countries is 0293 with a minimum of 0222 and maximum of 0558 confuciandummy has a mean of 0060 and median of 0 suggesting that 1 in 16 countries or regions in our sample is classified as confuciancircle the mean of ln in the sample is 2436 ranging from 0001 to 7273 with a standard deviation of 1509 the mean of sars is 0087 indicating that a small number of countries in the sample experienced sars in 2003 8 a mean of 888 of the population is aged over 65 as measured by ln the economic development of the sample countries varies significantly ranging from 6494 to 11669 with a standard deviation of 1196 smoke has an average of 2139 indicating that less than a quarter of the sample population are smokers finally protestants catholics and muslims respectively account for 1207 3094 and 2372 of the population results effect of collectivistic culture on the spread of covid19 we conduct an ordinary least squares regression analysis of the effect of collectivistic vs individualistic culture on the spread of covid19 after controlling for continent and monthlevel fixed effects we regress the spread rate of covid19 on the collectivism culture scores where higher scores reflecting greater orientation toward a collectivistic culture consistent with our expectation the higher the collectivism culture scores the lower the covid19 spread rate for a country or region in particular the coefficient of the key variable of interest collectivistic is negative and significant in a simple regression specification in model it remains negative and significant after we include a set of control variables in model the latter result indicates that for every one standard deviation increase in the collectivism score the weekly case growth rate decreases by 138 regarding the control variables in the regression results we note some important findings relevant to the factors associated with the spread of covid19 generally consistent with previous studies we find that the covid19 spread rate is lower for countries or regions that experienced sars in 2003 and have higher gdp per capita more people older than 65 and more protestants conversely covid19 spread more rapidly in countries with larger populations more smokers less media influence on public affairs and more muslims specifically the coefficient of sars is negative and significant and the covid19 spread rate decreases by a mean of 2309 in countries or regions that experienced sars furthermore economic condition is negatively associated with covid19 spread rate as indicated by a negative and significant coefficient of ln every one standard deviation increase of gdp per capita is associated with a 198 decrease in the covid19 spread rate the percentage of the population aged over 65 is another factor influencing the spread of covid19 as indicated by a negative and significant coefficient of age65 this may be because elderly people tend to remain at home during a pandemic resulting in a lower covid19 spread rate notably there is a negative association between protestant population size and covid19 spread rate but a positive association between muslim population size and covid19 spread rate this may be related to more suspensions of community gatherings among protestants which reduces transmission risk reddy et al and patanavanich and glantz report that patients with a smoking history have a significantly increased risk of severe covid19 we also find a positive relationship between smoking prevalence and the spread of covid19 furthermore weaker government policy enforcement as denoted by a higher value of ln is associated with a higher covid19 spread rate as indicated by a positive and significant coefficient of ln notably we obtain an rsquared of 0573 in model when collectivistic culture is the only explanatory variable implying that more than half of the variance in covid19 growth rates can be explained by levels of collectivism across the sampled countries or regions after we include a set of control variables in model the rsquared increases to 0608 illustrating that our regression models not only fit the data but also provide evidence that collectivistic culture indeed has an important effect on the spread of covid19 overall collectivisticoriented cultures are associated with a lower covid19 spread rate in addition the results indicate that prior experience of sars higher gdp per capita larger population aged over 65 and more protestants are associated with a lower spread rate of covid19 in contrast covid19 cases spread more rapidly in countries and regions with larger populations weaker media and more catholics or muslims effect of confucian culture on covid19 spread the confucian philosophy of common good emphasises the honour of collectivism and discourages individualism in interpersonal interactions in society following ye et al we identify countries and religions that belong to the confucian cultural circle including china hong kong indonesia japan south korea malaysia the philippines singapore thailand and vietnam we then create confucian a dummy variable that equals 1 for these ten countries and regions and 0 for all other countries for use in the regression specification as shown in table 3 the coefficient of the key variable of interest confucian is negative and significant in models and implying that the countries and regions in the confucian cultural circle generally experience a lower covid19 spread rate than other countries the result in model indicates that the weekly case growth rate in the confucian cultural circles is on average 7598 lower than in other countries similarly we find that the covid19 spread rate tends to be lower in wealthy countries and countries with more people aged over 65 as indicated by negative and significant coefficients of age65 and ln covid19 cases tend to spread more rapidly in countries that have more population more smokers and more catholics or muslims covid19 also spreads more rapidly when the enforcement of policies is more lenient again we obtain higher rsquared values of 0543 and 0594 in models and showing that our regression models not only fit the data but also provide strong evidence for the important effect of confucian culture on the spread of covid19 do lockdowns work the covid19 pandemic has led governments across the world to implement unprecedented interventions and closure policies in an attempt to contain the virus governments have closed schools and workplaces cancelled public events restricted gathering closed public transportation issued stayathome orders and restricted internal movements and international travel some countries have imposed lockdowns that restrict movement as shortterm solutions to save lives 9 like any policy intervention the effects of these responses are highly contingent on local political social and cultural contexts nonetheless several studies have reported that lockdowns play an important role in preventing the spread of covid19 given our results showing that countries and regions with a collectivistic or confucian culture have a lower spread rate of covid19 a natural question follows would this cultural effect on the spread of covid19 become stronger during a national or regional lockdown to answer this question we first collect lockdown start and end dates from wikipedia for the countries or regions that implemented these restrictive policies during our sample period we then divide the sample into two subsamples lockdown period and nonlockdown period based on the lockdown dates and conduct regression analysis for each subsample table 4 compares the effect of collectivistic culture on the spread of covid19 during lockdown and nonlockdown periods the estimated coefficient of collectivistic is more negative and highly significant in the lockdown period subsample than in the nonlockdown period subsample a χ 2 test shows that the difference between estimated coefficients of collectivistic is significantly different from 0 between the two subsamples this result indicates that the negative effect of a collectivismoriented culture on the covid19 spread rate more than triples during lockdown periods compared to nonlockdown periods for every one standard deviation increase in our collectivism score the weekly growth rate of covid19 cases decreases by 404 during lockdown periods whereas it decreases by 124 during nonlockdown periods we similarly find that when using confucian as an independent variable it has a coefficient of 26169 and 7841 for the lockdown and nonlockdown subsamples respectively the difference between the estimated coefficients of confucian is 18328 which significantly differs from 0 overall the results in tables 4 and 5 support our hypothesis that the cultural effect on the spread of covid19 is stronger during national or regional lockdowns corroborating evidence from the effect of cultural tightness vs looseness first proposed by gelfand et al and harrington and gelfand cultural tightnesslooseness is another important dimension of a countrys culture it measures the degree to which cultures adhere to social norms and tolerate deviance tight cultures are restrictive and take strict disciplinary actions against the violation of norms while loose cultures have relaxed social norms and high tolerance for deviant behaviours people who grow up in a tight culture that strictly enforces rules do not typically support individualistic thinking or behaviour while those who grow up in a loose culture have more freedom regarding their behaviour and beliefs as tight culture facilitates more effective coordination of people to survive threats and natural disasters and is associated with increased government control and constraints in daily life we expect a lower covid19 spread rate in countries and regions that are more oriented toward cultural tightness we obtain the original cultural tightness scores for 31 countries from gelfand et al and merge these with the covid19 data resulting in 10095 observations in the final sample we use ln in the regression analysis which has a mean of 1774 with a standard deviation of 0478 the minimum and maximum are respectively 0470 and 2510 we provide cultural tightness scores for all countriesregions in appendix c consistent with previous research the pearsons correlation coefficient between tight score and the collectivistic culture index for this merged sample is 0380 indicating a moderate correlation between these two measures of cultures 10 we then regress covid19 spread rate on the cultural tightness scores ln and control variables consistent with our expectation ln has a negative and significant coefficient in models and showing that countries and regions with tight cultures generally experience a lower spread rate of covid19 than countries with loose cultures the effects of the control variables are generally consistent with those revealed in previous models cultural effect on covid19 death rate overall our findings indicate that countries or regions with collectivistic confucian or tight cultures tend to have lower spread rates of covid19 we subsequently expect that analogous cultural effects also occur with respect to covid19 related deaths to examine the potential cultural effect on the covid19 death rate during the sample period we define deathgrowth as ln ln where coviddeaths it and coviddeaths it7 are the numbers of confirmed covid19 deaths on day t and day t7 respectively we use deathgrowth as the dependent variable and conduct a regression analysis including the same control variables as in previous analyses as shown in table 7 the coefficients for collectivistic confucian and ln are all negative and significant across three regression specifications implying that countries or regions with collectivistic confucian or tight cultures tend to have lower covid19 death rates 11 discussion and conclusions conclusions the covid19 pandemic has presented unprecedented challenges and greatly altered both normal life and economic activities in collectivistic societies people usually prioritize grouporiented concerns over their personal interests and conveniences such as freedom and privacy as a result people in collectivistic cultures are more likely to sacrifice their personal interests for the groups needs and goals for example people in collectivistic cultures are more willing to tolerate personal inconvenience and wear masks during the pandemic on the other hand compared with individualistic societies collectivistic societies have stronger social norms and encounter fewer difficulties during the pandemic governments in countries with collectivistic cultures tend to react more quickly than those in countries with individualistic cultures therefore collectivistic societies are more likely to experience a lower spread rate of covid19 than individualistic societies in this study we investigate the spread of covid19 cases by considering cultures across different countries and regions of the world our findings are consistent with our expectations after controlling for factors at the national level including population age structure gross domestic product per capita previous sars occurrence smoking prevalence and religion we find that countries and regions with cultures that emphasise collectivism rather than individualism experience a lower spread rate of covid19 considering the effects of confucian culture and cultural tightnesslooseness on the spread rate of covid19 we find that countries and regions in the confucian cultural circle or those with tight cultures generally experience lower covid19 spread rates examining the cultural effect on covid19 death rate corroborates these results overall our results are not consistent with webster et al but consistent with jiang et al and maaravi et al both of which report that collectivistic societies have fewer covid19 cases than individualistic societies compared with maaravi et al and jiang et al our study further reports that the effect of collectivistic cultures on the spread of covid19 becomes stronger during national or regional lockdowns therefore our study contributes to the literature by showing that the degree of collectivistic orientation affects not only the spread of covid19 but also the outcome of lockdowns implications our study has important practical implications for controlling the spread of infectious diseases first in light of the significant cultural effects on the global spread of covid19 identified in this study we recommend that governments implement policies that emphasise the ideas of the common interest personal responsibility and strong norms and the sense that we all live in a global community second since the effectiveness of lockdown policies depends on the degree of collectivistic orientation we recommend that governments highlight the collective benefits from lockdowns and the importance of adhering to social norms before implementing lockdown policies especially in western europe and north america where people endorse individualism third considering that the world is becoming more and more interconnected we recommend that governments in different countries and regions collaborate on solving the collective crises like covid19 pandemic as people all live together in a small global village finally our recommendations may still hold for future similar infectious diseases besides our study does not suggest that collectivism outperforms individualism in any conditions vaccines may be more important than cultural factors in the later stage of covid19 pandemic limitations and future research first in our study we use regression models to estimate the effects of cultural factors on the spread of covid19 however regression models fail to show the covid19 spread process in the real world and may ignore some important factors existing literature has shown that higherorder interactions have significant impacts on the epidemic spreading for example the collective behaviour in higherorder networks often leads to super spreading events during the pandemic so it is necessary for researchers to study the impact of higherorder networks on the spread process furthermore who has reported that different variants have emerged and been identified in many countries variants suppress each other through competitive behaviour which may influence the pandemic transmission dynamics li et al present a competing spread model for two simplicial irreversible epidemics on higherorder networks to show the spread process of two epidemics however there is a lack of systematic research on epidemiological immunization strategies on higherorder networks considering the importance of higherorder interactions we argue that future research could examine the influence of higherorder interactions on the spread process second in our study each countryregion has a fixed collectivistic culture score however cultures are actually dynamic and changing all the time for example people in collectivistic cultures may be unwilling to support lockdown policies after they have been locked down for several months we may need to find a balance between freedom and constraint third our study only examines the effects of collectivist tight and confucian cultures on the spread of covid19 however cultures are complex and have different dimensions other cultural dimensions may be also important future research could examine how other cultural dimensions affect the spread of covid19 data availability the datasets generated and analyzed during the current study are available from the corresponding auther upon reasonable request notes 1 according to orbann we are both biological and cultural beings so when a disease spreads through large parts of the worlds population we can cope with that in both biological and cultural ways… every major pandemic in human history has been exacerbated by cultural behaviour in one way or another the meeting prompted countries across the world to pay attention to covid19 before 22 january 2020 covid19 had not received substantial attention and no covid19 case data had been collected and reported to the public we end our data on 31 december 2020 as the vaccine as this is when vaccines became widely available in many countries our study thus does not consider the effect of widespread vaccination on the spread of covid19 8 15 countries experienced sars outbreaks china australia brazil colombia india indonesia italy malaysia ireland south korea south africa spain thailand the uk and the usa 9 these countries include china france italy spain and the uk among others some studies report that government interventions such as lockdowns may severely affect peoples mental health 10 harrington and gelfand report a correlation of 037 between the collectivism measures and tightness scores 11 note that the results reported in this section are subject to interpretation it has been reported that covid19 deaths are primarily related to preexisting medical conditions our regression analysis does not include this important variable due to data limitations competing interests the authors declare no competing interests ethical approval this article does not contain any studies with human participants performed by any of the authors informed consent this article does not contain any studies with human participants performed by any of the authors additional information supplementary information the online version contains supplementary material available at correspondence and requests for materials should be addressed to haomin wu reprints and permission information is available at publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

while previous studies have emphasised several important factors associated with the spread of covid19 and strategies to reduce transmission few studies have focused on the social and cultural factors that may influence its spread this study analyses the spread of covid19 from a crosscountryregion cultural perspective and finds that countries and regions with a collectivistic confucian or tight restrictive culture experience a lower spread rate of covid19 the results are robust to controlling for several factors including population age structure gross domestic product gdp per capita previous sars occurrence smoking prevalence and religion a one standard deviation increase in the collectivism score is associated with a 138 reduction of the weekly growth rate of covid19 cases more importantly the effect of culture on the spread of covid19 becomes stronger during national or regional lockdowns corroborating these main results supporting analyses find a significant effect of culture on national and regional covid19 death rates these findings suggest that to manage the ongoing surges in covid19 outbreaks governments should implement public health policies that emphasise the ideas of common interest personal responsibility and strong cultural norms and sense of community as this pandemic has revealed that people all live together in a small global village why did korea japan taiwan have so few deaths i see facecovering and the confucian idea of common good as key michael levitt the nobel prize laureate 2020

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the growing cancer mortality poor access to palliative care treatment hesitancy poor survivorship and limited oncology healthcare infrastructure have been investigated in subsaharan africa in nigeria the orthodox treatment and management of cancer is still greatly influenced by superstitious belief and spiritual connotations yet the sociospiritual and culturally sensitive meanings attached to cancer and treatment are still lacking in the literature this study explored the sociospiritual strategies of older adults living with cancer in nigeria the study adopted a qualitative approach and data were collected through a semistructured interview with 15 older adults from the oncology unit university of nigeria teaching hospital enugu state nigeria the data were managed and inductively coded using nvivo 12 and analyzed thematically the findings of our study show that cancer is traditionally conceptualized as the aftermath of a disconnection with supernaturalancestral forces by implication such misconceptions affect the level of dispositions and steps taken toward diagnosis and treatment to this end our study argues that blending spiritual needs social support and culturally sensitive cancer education could improve the quality of life and coping capacity of older adults living with cancer the study recommends the infusion of sociospiritual interventions to cancer treatment for older adults in nigeria abstract citation id igad1043338 exploring the stressrelated growth among elderly korean immigrants in the context of covid19 pandemic jooah lee 1 yongseop kim 2 hyejin park 3 and junhyoung kim 3 1 henry m gunn high school palo alto california united states 2 indiana university bloomington indiana united states 3 texas a m university college station texas united states while some studies investigated stressrelated growth during the covid19 pandemic little research has been pursued to explore positive psychological changes associated with covid19 among older asian immigrants thus we aimed to find positive changes resulting from the covid19 pandemic based on the srg framework using a purposeful criterion sampling strategy semistructured indepth interviews were conducted with 11 participants content mapping and content mining questions were used data were qualitatively analyzed using the constant comparative method challenges and stressors associated with the pandemic such as fears of physical or verbal attack covid19 infection strict covid19 regulations and mandates and limited opportunities to interact with others were identified based on the statements of participants we identified three salient themes that were characterized as components of srg increasing leisuretime physical activity participation developing a closer relationship with others and improving resilience the findings of the present study present qualitative evidence that older korean immigrants experienced positive changes associated with the pandemic such as being physically active developing closer relationships and improving resilience these changes are associated with the main elements of srg and it appears that the pandemic did lead to older korean immigrants experiencing srg

neighborhood safety trajectories that may relate to healthy aging this qualitative study used data from a sample of participants in adulthood and older adulthood aged 3589 mage 64 years from two predominantly black lowincome neighborhoods that have had different histories with regard to disinvestment and systemic racist policies we used 60 indepth interviews to explore perceptions around neighborhood safety trajectories and their perceived impact on aging outcomes the results highlight several dimensions of perceived changes in neighborhood safety over time and how these are perceived to relate to aging outcomes eg psychological stress the findings also show a few differences between the two neighborhoods concerning policing strategies individual behaviors and resource availability all of which may contribute to perceptions of safety implications of this work highlight the importance of developing culturally relevant interventions that target upstream social determinants of healthy aging and health disparities